WILCOX COUNTY ALABAMA: Needs Assessment School of Public Health University of Alabama at Birmingham Amy Louise Badham June 1993 Wilcox County, Alabama: Needs Assessment Table of Contents Page List of Figures List of Tables List of Appendices iv FORWARD vi ACKNOWLEDGMENTS vi EXECUTIVE SUMMARY 1 INTRODUCTION AND STATEMENT OF PURPOSE 3 NATIONAL AND REGIONAL BACKGROUND INFORMATION 6 Poverty 6 Enterie Disease 7 Water and Sanitation 3 Maternal and Child Health 9 DESCRIPTION OF STUDY COWUNITIES 10 Demographics 10 Services 11 Schools 12 Water and Sanitation 14 Health Facilities 15 Vredenburgh 1 3 Wilcox County, Alabama: Needs Assessment RESEARCH METHODS Household Surveys Health Care Provider Surveys Chart Audits Stool Samples RESULTS and DISCUSSION Household Surveys Health Care Provider Surveys Chart Audits Stool Samples CONCLUSIONS AND RECOMMENDATIONS FOR PROGRAMS AND FUTURE RESEARCH APPENDICES BIBLIOGRAPHY 117 Wilcox County, Alabama: Needs Assessment List of Figures Page 1. Household Questionnaire Protocol 24 2. Vredenburgh Survey, 2x2 Table, Chi-square 32 List of Tables Page 1. Christmas Sample, Comparison of the Actual Number Sampled vs. Weighted Sample 22 2. Comparison of Socioeconomic, Demographic, and Environmental Characteristics of Cases and Controls in Vredenburgh Survey 33 3. Comparison of Socioeconomic, Demographic, and Environmental Characteristics of Cases and Controls in Christmas Survey 35 4. County Data Set: Association Between Major Variables and Enteric Disease 37 5. Vredenburgh Data Set: Association Between Major Variables and Enteric Disease 39 6. Christmas Data Set: Association Between Major Variables and Enteric Disease 40 7. Results of the Health Care Provider Surveys 43 Wilcox County, Alabama: Needs Assessment List of Appendices Page A. Postneonatal Diarrheai Mortality in the United States, 1973-1933 55 B. Map of Alabama Public Health Areas and Counties 56 C. Wilcox County Fact Sheet, based on 1990 Census Data 57 (cont'd). 1990 Pro?le of Alabama 59 (cont'd) 1990 Pro?le of Wilcox County 60 (cont?d) 1991 Pro?le ofWilcox County 6] D. Percent of Population Eligible for Medicaid; Fiscal year 1991 62 E. Map of Wilcox County: Census Tracts Schools 63 F. "Wilcox County school system's woes are legion", Birmingham News, Sunday, August 29, 1992 64 G. Map of Wilcox County: Health Care Facilities 65 H. Map of Vredenburgh Quarter, as of Nov. 1991 66 I. Wilcox County Community Needs Assessment: Household Questionnaire 67 J. Health Care Provider Survey 75 K. Prevalence of Intestinal Helminths, Wilcox County, Alabama Stool Sample Survey 79 L. Wilcox County: Results of Household Surveys 81 M. Results of Household Survey for Children with Diarrhea 90 N. Chart Audit-Alberta Clinic, Patients under 10 seen 7f91-6f92 Diagnosis=Enteric Pathogen, Original and Follow-up Audit 98 0. Chart Audit of Children participating in UAB Stool Sample Survey, From the Alberta Clinic 106 iv Wilcox County, Alabama: Needs Assessment Page P. "More than presciptiens", Birmingham New, Sunday, December 20, 1992 111 Q. Wilcox County Phone List 115 Wilcox County, Alabama: Needs Assessment mums Two Master's students, Ms. Erin Branigan and Mrs. Amy Badham, from the School of Public Health at the University of Alabama at Birmingham (UAB) conducted their ?eld research projects in Wilcox County, Alabama during the fall and winter of 1992. Investigating a possible association between poor sanitation and childhood morbidity, they spent August through October in the county interviewing key informants, visiting local service agencies and schools, administering provider surveys to local health care professionals, collecting chart audit data from four rural health clinics, and conducting a household survey in Vredenburgh. In late October they returned to the county with professors from the School of Public Health to set up a stool sample survey at the four rural health clinics. In December, accompanied by four other students, they visited the county again to complete the household survey in the remainder of the county. In February of 1993, due to some questions concerning chart audit data and the stool sample survey, Ms. Branigan and Mrs. Badham visited the Alberta health clinic to conduct a follow-up chart audit. Since beginning their research in Wilcox County the two researchers have presented their ?ndings and impressions in the form of an oral presentation to two groups of faculty and staff at the UAB School of Public Health. Ms. Branigan has submitted a pro-proposal to the Thrasher Foundation for a grant to set up a demonstration project in the county utilizing intermediate technologies to remedy the problem of inadequate sanitation that plagues many poor residents. Ms. Branigan also worked on the full proposal to complete her Master's level paper. The Thrasher Foundation has recently requested that a full proposal for this project be submitted in July 1993. Mrs. Badham has completed this Needs Assessment of the county which focuses on health care and sanitation. Both Ms. Branigan and Mrs. Badham are currently working with the School of Public Health and the Alabama Cooperative Extension to set up and conduct a focus group in August 1993, to formally present the data from the Needs Assessment and initiate further discussion about perceived needs of the community, and a town metting in the fall, to facilitate public policy deliberation amongst county leaders concerning water and sanitation problems. ACKNOWLEDGMENTS The two researchers and the UAB School of Public Health would like to thank the residents of Wilcox County for their cooperation in making this project a success. In particular, we want to thank Dr. Sharon Farley and Ms. Sheryl Threadgill and the rest of the staff of the Kellogg for serving as such wonderful hosts during the time we spent in the county. We want to say a very special thank you to Dr. Cook and the rest of the staff at the Pine Apple Clinic, the staff of the Alberta Clinic, Dr. Moskovich and the staff at the Yellow Blu?? Clinic, and Sister Pat Hauser and Sister Mary Rouleau and the rest of the staff at the Vredenburgh Clinic. All four clinics were very helpful and responsive to the provider survey, the chart audit, and the stool sample survey. Wilcox County, Alabama: Needs Assessment Other health care providers that we would like to achiowledge for their participation in the provider survey include: Dr. White, Dr. Blackmon, and Dr. Nettles. Thank to the two school nurses for the Wilcox County public school Mrs. Edna Richardson and Mrs. Mary Whiting, for sharing their knowledge about childhood morbidity and taking us on tours of two of the schools. We also want to thank the staff at the Wilcox County Department of Health and the J. Paul Jones Hospital. We especially want to thank Mr. Robert Jones for, so patiently, explaining the water and sanitation problems of Wilcox County to us. Thank you to the members of the Wilcox Community Health Council, the Department of Human Resources, the Alabama Tombigbee Regional Planning Commission, the Wilcox County Cooperatve Extension, and the Rural Health Initiative for sharing their time and information about the county with us . Thank you to Dr. Charles Stephenson, Dr. Pauline Jolly, and Osmond Banaga for setting up the stool sample survey. Finally, a very special thank you to all the residents of Wilcox County and Vredenburgh who so willingly let us into their homes and answered all the questions as they participated in our household survey. Erin Branigan and Amy Badham would like to extend their thanks to Dr. Walter Mason, Dr. Charles Stephenson, Vee Stalker, Pat Birch?eld, and the staff of West Alabama Health Services for their support of us throughout this ?eld research project. vii EXECUTIVE SUMMARY This Needs Assessment of Wilcox County, Alabama examines the relationship between enteric diseases among children under 10 and conditions associated with poverty in the rural South. A representative county-wide household survey, a health care provider survey, chart audits at the 4 rural health clinics, and a clinic-based stool sample survey are the methods used to examine this relationship. This Needs Assessment also identi?es the basic perceived needs of the residents, the health care providers, and many key informants in the county. Problem areas that are identi?ed include: widespread poverty and unemployment, poor housing conditions, a lack of transportation, a weak public school system, a lack of access to prenatal care and delivery services, and a serious lack of an adequate water supply, plumbing, and sewage disposal. The Household Surveys show that 15% of households do not have a standard ?ush indoor toilet; 35% use some method other than public sewer or septic system for sewerage disposal with 16% piping sewage out onto the ground near the house; and 69% see existing toilet facilities as a problem. In Vredenburgh. a signi?cant relationship is seen between enteric diseases in children under 10 and inadequate sewage disposal The health care providers cited a poor water supply, poor sanitation, unsanitary living conditions, and poor personal hygiene as the major causes of diatrhea. They felt that the prevalence of enteric disease in young children is average to high. The age group they consider to be the most susceptible is younger than 10 years. Speci?c communities that they identi?ed as having an excess of enteric disease are Alberta, Boykin, Pine Hill, and Vredenburgh. These are the same communities that the county sanitarian pointed out as problem areas. The chart audit revealed an excess of enteric disease; particularly in the northwest portion of the county. At the Alberta Clinic 33.7% of patients under 10 years old seen during the 1991-1992 ?scal year were diagnosed with intestinal helminths. Suggested interventions for the county include: development of a health education curriculum for the schools focusing on nutrition and hygiene, a pilot project using intermediate technology to remedy the sewage disposal problems; continuing education for the health care providers focusing on diagnosis and treatment of enteric disease. Future research should include: looking at the prenatal care and pregnancy outcomes of women in Wilcox County following the implementation of the Medicaid Waiver; studying the constructed wetland project (an alternative to a standard septic system) at the elementary school in Pine Apple to determine whether it may be a practical solution to some of the sanitation problems in this region of Alabama; and following up of the sanitation pilot project to determine whether the use of intermediate technologies is a feasible solution to the lack of adequate sanitation and using this information to institute policy change at the state level. INTRODUCTION AND STATEMENT OF PURPOSE The 1980's witnessed a disturbing increase in the percentage of children living in poverty, the rate climbing to over 22%. At present it is estimated that approximately one in ?ve children residing in the United States lives in poverty. Nearly one halfof all black children live in families with incomes below the poverty level. At present one in ?ve families in the United States is headed by a woman; with approximately half of all poor children living in female-headed households (1). Childhood poverty has been linked to a variety of speci?c health problems. It can be seen as elevating the likelihood of poor health by two possible mechanisms: the enhancement of risk for poor health and the reduction of access to those interventions effective at minimizing the impact of this elevated risk (1). The major acute conditions for children under the age of ?ve reported in the most recent National Health Interview Survey, an ongoing project of the National Center of Health Statistics, were respiratory conditions (including colds and the flu), acute ear infections, infectious and parasitic diseases, and injuries (2). Children of poor families experience more time lost From school and more days of restricted activity due to these illnesses than do those who are not poor. The inadequacy of their diet often produces signi?cantly elevated rates of iron-de?ciency anemia and failure to thrive among poor children. Inadequate housing conditions also affect morbidity, as lead poisoning is heavily concentrated in poor children. Poverty's in?uence on childhood morbidity also can be conveyed by the reduced utilization of effective clinical interventions (1). Non-metropolitan areas have higher poverty rates than other geographic areas. In 1938, the poverty rate in non-metropolitan areas was 16% compared with 13.1% across the nation and 12.2% in metropolitan areas. In 1984-85, 25.9% of children and youth under 21 in rural areas were poor. This is in contrast to 19.3% in metropolitan areas. Children in rural areas were also found to visit the physician less often (2). In the late spring of 1992, a group of faculty from the University of Alabama at Birmingham (UAB) School of Public Health who had a conunon interest in doing research in Wilcox County, Alabama began making plans to perform a preliminary study of the county. Their interest had been sparked by Dr. Sharon Farley, a professor in the School of Nursing at Auburn University at Montgomery (AUM), who also directs the Kellogg Project which is an ongoing community development project in Wilcox and Lowndes counties. During the course of the project, Dr. Farley noticed that there may be an excess of enteric diseases amongst the children living in Wilcox County. Dr. Farley in conjunction with the UAB faculty decided that the best approach to begin investigating this hypothesis would be to send two researchers (Ms. Erin Branigan and Mrs. Amy Badham, the author) into the county to conduct a Needs Assessment, looking into these particular claims and perhaps substantiating them. The principal purpose of this project was to collect data on enteric diseases among children of Wilcox County. These diseases, while not reportable to the State, often represent a considerable amount of morbidity. Most of them affect nutritional status of the infected child, and since they are recurrent, may result in considerable treatment cost, loss of energy, and loss of learning capacity in the affected children. The goals of the project were identi?ed as the following: 1. To collect data on enteric diseases among children under 10 years old in Wilcox County, Alabama; 2. To determine whether there is a correlation between the incidence of poor and the incidence of these diseases; and 3. To determine the perceived needs of the community related to morbidity and sanitation. In order to accomplish these goals our speci?c objectives were to: 1. Develop, pretest, and administer a household questionnaire county-wide to gather data on childhood morbidity and practices and conditions; 2. Interview key informants, including health care providers, to determine perceived problems; 3. Review existing data on enteric morbidity through chart audits at the rural health clinics; 4. Perform stool analyses for children less than 10 years old to determine the current prevalence of enteric disease; and 5. Identify geographic clusters of enteric disease or diseases associated with poor housing and examine their relationship with inadequate sewage disposal. All of this information would he gathered with the intention of using the data to design interventions for prevention of enteric disease. The Alma-Ata Conference has de?ned primary health care as "Essential health care made accessible to individuals and families in the community by means acceptable to them, through their ?ill participation and at a cost that the community can afford." Appraisal of the impact of a primary health care system on household health knowledge, attitudes, and practices makes little sense unless the essential elements of the system are available to the community. The Alma-Ate Conference recommended that primary health care include at least "education concerning prevailing health problems and the methods of identifying, preventing, and controlling them; promotion of food supply and proper nutrition, an adequate supply of safe water and hasig sanitatipn; maternal and phild health care; I imrmmization against the major infectious diseases; prevention and control of locally endemic disease; appropriate treatment of common diseases and injuries; prgmotion pf mental health and provision of essential drugs." Noticeably, most of the recommendations emphasize health promotion and disease prevention rather than the curative services that tend to be the primary concern of national health care delivery systems worldwide (3). In the Needs Assessment of Wilcox County the adequacy of these essential elements will be focused on. NATIONAL AND REGIONAL BACKGROUND INFORMATION Poverty Nearly 19% of Alabama's 4.2 million residents live at or below the poverty level (4). The Center on Budget and Policy Priorities in Washington recently reported that ?Alabama ranks Slst, or last among the 50 states including the District of Columbia, in the levels of Aid to Dependent Children (ADC) bene?ts it provides to poor families with children. Not only are Alabama welfare payments the nation's lowest, the system discourages recipients ?'om getting jobs. The program does not allow any ADC assistance to families in which both parents live in the home. Also the income levels to qualify for ADC are so unrealistically low that they encourage fraud. And the state Medicaid program is tied to ADC, which severely limits medical bene?ts for many of Alabama's poor residents. Nationwide, the single most important health program for low-income children is Medicaid. It accounts for over 55% of all public expenditures for child health, 26% of all hospital payments for children under the age of 6 years, and 10% of all payments for pediatric ambulatory care (1 However even with the existence of such entitlement programs as Medicaid, data ?oor the Population Survey of the US. Bureau of the Census show that in 1985, 17% of the population under age 65 years -- nearly 37 million people -- lacked any form of insurance for medical care, including Medicaid. One third of the uninsured were children. Among uninsured children 39% live below the federal poverty line, 10% live at 100 to 124 percent of poverty, and 22% live at 125 to 199 percent of poverty. Those most likely to lack health insurance are the children of the working poor; two?thirds of uninsured children live in families headed by a worker; and roughly half of these families are single- parent households (1). Some studies have shown that thousands of Alabamians who live below the poverty level fail to ?nd the little help that they do qualify for. Because many of them live in the rural areas and have no transportation and little access to information about social services, more than a third of them fail to receive food stamps, subsidized housing, and school lunches (4). Enteric Disease Childhood poverty has often been linked to morbidity and mortality. When national mortality data for 1973 through 1983 were reviewed to assess the importance of diarrhea] disease as a cause of preventable childhood death in the United States it was discovered that an average of 500 children aged 1 month to 4 years died each year with diarrhea reported as the cause of death. These diarrheal deaths were most common among children who were younger than 1 year of age, black, low birth weight, and living in the South. Both race and region of residence were most strongly associated with diarrhea] mortality. Black infants were four times more likely to die of diarrhea than were white infants. In some Southern states, diarrheal mortality for black infants was ten times that for whites (Appendix A). In Mississippi, review of fatal cases of diarrhea found that maternal factors (black race, young age, unmarried status, low level of education, and little prenatal care) were associated with diarrhea] death in the child. These ?ndings suggest that diarrheal deaths may be preventable and that targeted interventions could contribute to improved child survival in the United States on the whole (5). Another group of enteric diseases that are often linked to poverty are intestinal parasites. The southeastern United States has a subtropical climate where the temperatures are mild and the humidity is high, the moist soil providing an environment conducive to the survival and transmission of several parasitic organisms. Thus a large number of parasitic diseases might be expected. Several investigators have assessed the prevalence of intestinal parasites and the morbidity and mortality arising therefrom, providing de?nitive documentation that parasitic diseases are still prevalent in the United States (6). Ascariasis or roundworm infection is a common and important infection: it is estimated that perhaps a quarter of the world's population is burdened with it. Infections are most common in circumstances where people are crowded together under unsanitary conditions. The prevalence and intensity of infection rises rapidly in early childhood (7). In a study looking at the effect of ascariasis upon the nutritional status of children, it was found that children who had ascaris were 2.1 centirneters shorter in height, 0.6 cm thinner for mid-arm circumference, and 0.33 kilograms lighter in weight compared to matched children who were not infected. It has also been concluded that ascaiiasis contributes signi?cantly to malnutrition where both coexist (8). In a second study that looked at the e?'ects of parasitic infection on the cognitive processes of children, the pattern of results was consistent with the hypothesis that parasitic infections combine with nutritional de?cits to impair the ef?ciency of cognitive processes, in particular the attentional processes (9). Even with the evidence that parasitic infections have long-term e??ects on the growth and development of children, there are those who consider parasitic infections such as Ascaris unimportant because they do not usually cause acute and obvious disease. And due to the fact that reinfection is often highly likely infections may be left untreated Water and Sanitation Safe water and basic sanitation are two essential elements of the primary health care system. However, much of rural Alabama remains without public water and sewage services. While each year more Alabamians have gained basic water service via millions of dollars in government grants, some 500,000 -- almost one-seventh -- of the state's residents aren't on a water system according to the Alabama Department of Environmental Management (10). Since many Alabamians obtain their water from shallow wells and ground water sources, the quality is often questionable. According to 1980 Census Data on sewage disposal options in the United States; only 53% of Alabamians were on public sewers, 42% were on septic tanks or cesspools, and 5% used other means. These ?gures compare with the following averages for the United States: 74% on public sewers, 24% on septic tanks or cesspools, and 2% using other means. According to the same data for 1990; 54.5% of Alabamians were on public sewers and 45.5% used septic tanks, cesspools, or other means of disposal. While the percent of people served by public sewer is rising, there is still a large group of people who lack an adequate means of disposing of sewage. It is this group that uses "other means" or that lacks an adequate means that may be at a greater risk for fecal-oral transmitted diseases. Maternal and Child Health Finally, in a state where the infant mortality rate is higher than the national average and where the prevalence of low birth weight infants compares with that of developing countries it is no surprise that as many as a third of Alabama mothers who gave birth in 1990 did not receive adequate prenatal care. In some counties the number of women receiving inadequate prenatal care reached as high as 69%, about twice the national average. The lack of adequate prenatal care is just one of many maternal-child health problems currently facing the state. Maternal delivery services were only available in 33 of the 67 counties in Alabama in 1990. It has also been discovered that in 36 counties more than one ?fth of babies born in 1990 had teenage mothers. And about 30% of all births in Alabama were to unmarried women, as compared to a nationwide average of 27%. Five counties, however, had more than twice the state average of unmarried mothers. These counties included: Bullock, Greene, Lowndes, Macon, and Wilcox (11,12). DESCRIPTION OF STUDY COMMUNITIES Wilcox County was selected as the study community because of anecdotal information that was relayed to faculty of UAB School of Public Health by members of the Kellogg project, an comnmnity development project in Wilcox County funded by the Kellogg Foundation, concerning the possibility of a disproportionate amount of enteric disease amongst young children in the county. The possibility that this may have a relationship to the large amount of inadequate and inappropriate sewage disposal was con?rmed by the county?s sanitarian. Demographics Wilcox County is located in the southern part of the Alabama in what is known as the Black Belt, due to the fertility of the soil in this region (Appendix B). The countfs land area is 581,171 acres most of which is forest land owned by timber companies. In fact 72.4% of the land area is forest, 23.1% is agricultural, and a mere 0.6% is considered urban or ?built up" (13). A population of 13,568 reside in Wilcox County, Alabama. The racial breakdown of the county is 31% of the residents are white and 69% are black. It is ranked among the poorest counties in the nation with 45% of its population living below the poverty line (14,15). Other statistical indicators give a broader picture of this rural county (Appendix C). In 1930, Wilcox County, Alabama was ranked the 6th poorest county in the United States based on the percentage of people living below the federal poverty line, de?ned as an income of up to $13,924 for a family of four. Nearly half of the county's residents were living below that level. In 1990 according to the Census Bureau, Wilcox's ranking moved up to 25th in the nation, however, 45.2% of the population still live below the federal poverty line (15). 10 Wilcox County is a rather large rural county with its population spread throughout. Many of the residents are without any form of transportation. No federal highways run through the county, only state and county roads. This creates a serious problem with access to health care for many patients, as well as isolating the county from external revenues and employment opportunities. The county has several phone companies that operate within its borders, so many inter-county calls -- perhaps to the doctor -- are long- distance. The county's main industry is forestry. The largest industrial employer is MacMillan Bloedel, a Canadian paper company. They employ 1,500-2,000 county residents. Machiillan Bloedel provides more than just jobs and revenue to the county. They support the hospital in Camden by buying expensive equipment for it and they fully ?nd a summer reading program for the county's children. The median household income is $12,237. This compares to $23,597 for the state and $3 0,056 for the nation. The percent of families living below the federal poverty line is the highest in the state, 45.2%. This compares with the state average of 14.8%. Unemployment in the county in October 1992 was 12.3 also the highest in the state of Alabama. The state's rate was 6.1% and the national average was 7.2% (16) Medicaid eligibility serves as another good indicator of poverty. Currently, 34.7% of the county's residents are Medicaid eligible. This, once again, is the highest rate in the state of Alabama and compares with a state rate of 11.9% and a national rate of 8.6% (Appendix D). Services There are many services available in the county for individuals and families in need. Some of the services available to poor county residents include: Aid to Dependent Children, the Food Stamp program, the commodities program, the school lunch program, a summer feeding program for children, and Medicaid. Some of the health care services 11 that are available through the Wilcox County Health Department include: family planning services, maternity care, W1C (Special Supplemental Food for Women, Infants, and Children) and EPSDT (Early and Periodic Screening, Diagnosis, and Treatment). The Kellogg Project does community development work with the elderly and the low-income. The project has set up tutoring sites throughout the county and work to spread health information out into the community through lay people. They also sponsor a program to train and certify low income women as nursing assistants. The Interagency Health Council, another of the county's service organizations, consists of the two school nurses, the health care providers, and the members of social service organizations. Their aim is the networking of many agencies for common welfare of the county. Programs that they sponsored include: a career fair at the high school, a women's health conference, a county resource handbook, and an AIDS coalition. Schools In Wilcox County there are two separate and distinct school systems. There is the public school system made up of 6 schools; 3 elementary schools, 1 Kindergarten-8th grade school, 1 middle school, and 1 high school. The public schools enroll approximately 2,850 students, 99.2% of which are black. There are also two private schools, Kindergarten-12th, in the county. Together these private schools enroll approximately 510 students, 100% of which are white (Appendix E). In the county, 19.1% of students are enrolled in private schools. This compares with a state average of 1 1.6% (13). There are also some students who go to school in Thomasville which is in a neighboring county. Of the county's population over 25 years old, 41.7% have graduated from high school and 9.5% have graduated from college. The state averages are 56.5% and 12.2% respectively (13). The graduation rate for the 1990-1991 school year for the county was 51.8%. This was lower than the state rate which was 66.8% (17). 12 The school system also has many other signi?cant problems. Over the last ten years there has been a serious problem with mismanagement of ?nds (18). The county recently built a $7.5 million high school. This occurred when many of the basic needs of the other schools in the system were not being met. This is a school system where many sinks and toilets are dys?inctional and where raw sewage until late ran out onto the playground at two elementary schools. Building this new high school as well as closing and consolidating many of the other schools in the county has led to increasing centralization which is said to harm the children's education (Appendix F). Wilcox County?s public school system ranked the lowest in the state according to the scores of high school juniors on the Alabama High School Graduation Exam. With only 56% passing reading, 50% passing math, and 39% passing language, Wilcox County students trailed students in most other systems by signi?cant margins (20). The Alabama Department of Education's report last June on the Wilcox County schools cited a "general deterioration of many facets of the educational process" in the system and said it was caused "mainly by the lack of leadership on the part of the administration." Many shortcomings were noted in the report including: no scheduled maintenance program for facilities, no regular monitoring of teaching programs, a serious shortage of textbooks, and employment of some teachers without state certi?cation (13). In September 1992, the Wilcox County Board of Education approved a plan that gave the State Superintendent of Education ?nal approval on all spending. This agreement was the ?nal step in what is seen as a virtual takeover by the state of a public school system heavily in debt and among the worst in the nation academically (19). Another major problem facing the school system is that two public elementary schools, Alberta and WJ. Jones, almost didn't open for the 1992-1993 school year because of sanitation problems. The septic tanks serving the schools had to be pumped daily in order to keep raw sewage ?'om seeping out on top of the ground. The schools were given 90 days to remedy the problem. Alberta Elementary received a new septic 13 system and WJ. Jones Elementary received a constructed wetland system to remedy their sanitation problems. Water and Sanitation There are approximately 2,056 households in the unincorporated area of Wilcox County that are without public water service. Those who are not served rely mainly on shallow wells and surface water sources of generally poor quality and unreliable quantity. The majority of those lacking public water service are of moderate and low income due to the very high percentage of those persons living in the unincorporated portion of the county. (21). Wilcox County, with the ?nancial help of the Kellogg Foundation, has recently provided safe water to many areas not previously served by a public supply. There are plans to extend the public water lines to reach even more of the county?s residents. However, one of the obstacles that will need to be overcome is that 28.4% percent of homes lack complete plumbing. This is the highest rate in the state which has an overall average of 4.2% (13). Also, problems of inadequate waste disposal remain in many of the unincorporated areas and within poorer neighborhoods of Camden. The commume health centers in Vredenburgh and Alberta and the county health department report that this situation may cause diarrhea and parasitic infections. Even the schools have had problems maintaining adequate, safe water and waste diSposal. Just four years ago, eight schools had a positive out?ow of sewage onto the ground. A middle school in the community of Annie Manic was closed a few years ago because of a high fecal coliform (E-coli) count in the water supply. Also as mentioned previously, two elementary schools had a problem with raw sewage running out onto the playground 0r backing up into the cafeteria before receiving new sewage treatment systems this year. There are ?ve municipalities in Wilcox County. The two largest, Camden and Pine Hill have public sewer systems that have recently been upgraded. The three others, Pine 14 Apple, Oak Hill, and Yellow Bluff rely on septic tanks and other means of sewage disposal (Appendix E). Septic tanks provide the main waste water disposal facilities in Wilcox County. County-wide problems with septic tank use are associated with variable soils restricting percolation and having seasonally high water tables. It is estimated that between 50% and 75% of the households in the county experience problems of some type with waste disposal (22). 0f the 13,568 residents of Wilcox County, 2,395 are served by existing sewer systems. There are 17 communities within Wilcox County identi?ed by the Alabama-Tombigbee Regional Planning Commission (ATRPC) currently in need of sewage disposal systems. This includes 3,745 county residents, or 23% of the county that is in need. Of this number approximately 2,244 of the residents are classi?ed as low or moderate income persons (22). The unincorporated sections of Wilcox County contain 10,673 of the residents. There are no sewer systems serving any of these rural areas. Poverty contributes to these sewage problems. Present regulation of the sanitary code limits the way wastes may be handled to methods that exceed the budgets of many rural households. The average cost of a septic tank and drain ?eld is reported to be approximately $3,000 in Wilcox County. Health Facilities There are four rural health clinics in the county. Two of them, the Vredenburgh Clinic and Alberta Clinic are ?nanced by the Catholic order of the Fathers of Saint Edmund. The other two health clinics, the Pine Apple Clinic and the Yellow Bluff Clinic, are operated by the Rural Health Initiative out of Selma. Pine Apple and Yellow Bluff are staffed ?Jll-time by a physician. Alberta and Vredenburgh are staffed ?ill?time by a nurse- practitioner and have a physician come in to see patients one day a week. The Pine Apple and Vredenburgh clinics, both staffed by nuns, also provide a number of other outreach 15 services for-their communities. Some of these services include: adult and child day care, tutoring, transportation, and elderly feeding sites. The J. Paul Jones HoSpital is the only hospital in the county. It was opened in Camden in 1957. This 32 bed hospital provides in-patient care and emergency services. The hospital stopped delivering babies in 1985. Pregnant women must now travel to a neighboring county and some drive as far as Mobile or Montgomery. The hospital is sta??ed by 40 employees including: 7 R.N.s, L.P.N.s, 4 aides, 2 orderlies, and 6 home- health employees. All of the physicians in the county take call with the exception of Dr. Nettles, a send-retired doctor who practices part-time. The county also has a private ambulance service. The Wilcox County Health Department is also located in Camden. They provide approximately 200 well-child health visits per month. It is estimated that the Wilcox County Department of Health sees 88% of the children in the county. Other services provided include: immunizations, the Supplemental Feeding Program for Women, Infants, and Children (WIC), family planning, cancer screening and a hypertension clinic. The health department does not providelany primary care to its clients. Sick patients are referred to the private physicians or the rural health clinics. The health department was recently named the preferred provider of prenatal care for Wilcox County under the Medicaid Waiver. This means that they are the only provider in the county that will be reimbursed by Medicaid for providing prenatal care. This has created a serious problem with sta?ing since the health department must now serve four times the number of prenatal patients as before when the rural health clinics could also be reimbursed for providing this service. The health department employs eight ?ill-time staff including: one nurse, one sanitarian, ?ve clerks, and one aid. Supplementing this staff are a couple of temporary nurses; a W1C nutritionist twice a week; a physician from Monroeville a few times a month to see high-risk prenatal patients; and Dr. White, a physician who has a private practice in Camden, two Thursdays at month to do the family '16 planning clinic. Currently there are ?ve doctors practicing medicine in Wilcox County. They are Dr. Blackmon, Dr. Cook, Dr. Moskovich, Dr. Nettles, and Dr. White. Dr. Blackmon and Dr. White are private MD's who have of?ces in Camden next to the county hospital. Dr. White also works twice a month at the V?lcox County Health Department and one day a week at the Alberta Clinic. Dr. Nettles is a semi-retired doctor who runs a small practice in Arlington, located in the western region of the county. He is still willing to barter for his medical services. He has been known to accept quilts or peas for services rendered. Dr. Moskovich, the acting physician at the Yellow Bluff Health Clinic, is working in the county to repay her medical school loans. Dr. Cook is a nun who has been working at the Pine Apple Clinic for nearly eight years. She also spends one day a week working at the Vredenburgh Clinics (Appendix G). There are also two school nurses that attend to the basic medical needs of the over 2,850 students enrolled in the public school system. One of them is for the Chapter 1 students. Chapter 1 is a supplemental instructional program that helps children in grades pro-Kindergarten through 8th to improve their reading, speaking, and writing skills. These students are identi?ed by academicfbehavioral characteristics, grades, or teacher recommendation as needing some extra help and support. Between 70 and 80% of the students in the public elementary and middle schools are in this program. The second nurse is for Students enrolled in Special Education. Their role is to strengthen the educational process by assisting students to improve or adapt their health status through detection, improvement, maintenance of their overall health. They refer sick children to the rural health clinics or the private providers for treatment. They also do some health education activities. Vredenburgh The community of Vredenburgh is located on the county line between Wilcox and Monroe County. It is a unique community with a population of 433, most of whom live at or below the poverty level. Vredenburgh is the third poorest community in the state of Alabama with a per capita income of $3,435. Vredenburgh was the site of a large paper mill until it burnt down in 1978, leaving the community without any employment opportunities. Physical and social isolation along with the lack of transportation are some of the most critical problems of this community following the lack of employment. The current unemployment rate is 18.6%. The community is physically divided by race. The white community occupies the old mill homes. However, only 12 of these 31 homes are occupied year-round. The black community, 90% of the residents in Vredenburgh, live in what is known as the Maple Street Neighborhood or the Quarter which literally lies on the other side of the tracks item the white section of town (Appendix H). The Quarter is divided into two distinct areas by the Wilcox/Monroe county line. The distinction is that in 1986 when Monroe County put in a public sewer system for the town, the sewer lines stopped at the county line. So the Wilcox residents of Vredenburgh lack adequate sewage disposal. Many of these homes pipe their sewage into a drainage ditch. It has been noted by the health care providers at the Vredenburgh Clinic that the children who live in this area have a higher rate of skin disorders than the children who have proper sewage disposal in their households. Because "the housing conditions in Vredenburgh had reached a crisis state with many being extremely unsafe for occupancy" (23), the town urged by Sisters who run and work out of the Vredenburgh Health Clinic applied for and received a number of Community Development Block Grants (CDBG). In 1984 a public water system was constructed. In 1986 a municipal sewer system was put in for Monroe County residents. And in 1990, ?fteen houses were renovated, eight by acquisition and relocation and seven 13 by rehabilitation. Currently, 64% of the occupied housing units are substandard, classi?ed as either dilapidated or seriously deteriorated. There are 78 persons living in this housing that is inadequate for human habitation. Although 100% of the population has access to the municipal water system, there is a serious inadequacy in the plumbing ?xtures of many of homes. There are eleven occupied units that lack complete plumbing facilities. Standpipes in the yard are the source of water and latrines or a neighbor?s bathroom serve as toilet facilities for these households (23). A sanitary survey of the Quarter in Vredenburgh was conducted by the Alabama Department of Public Health on January 23 1990. The report concluded that a lack of complete plumbing ?xtures, the lack of adequate sewer connections, and the condition of the housing "has all of the ingredients for serious health problems if left unattended The researchers spent a considerable amount of time in this community and the data that was collected from this area was analyzed separateiy from the rest of" the county. 19 RESEARCH METHODS The Wilcox County Needs Assessment consisted of a number of separate types of research. Surveys of households with children under the age of ten were conducted. Provider surveys were administered to 10 local health care practitioners. Chart audits were conducted at the four rural health centers. And a stool sample survey at the rural health ciinics followed the chart audits in hope of reinforcing their ?ndings. Household Surveys The Vredenburgh Survey. This survey took place during the ?rst week in October 1992, included 30 households with children under the age of it). The sample was selected with the help of outreach workers from the local rural health center. These outreach workers identi?ed all of the households in the area that contained children under the age of 10. This represented 40 of the 90 households in the immediate area. The two interviewers sampled 30 of the {10 identi?ed. The missing households were due to no one being home. Seventy children under the age of 10 were included in this sample. The Christmas Same); The two original interviewers along with four additional Master's students returned to the county in December 1992 to administer household questionnaires throughout the county.(Thus the name the Christmas sample.) The four students underwent training to familiarize themselves with the questionnaire and the proper procedure for administering it. This process was carried out over a seven day period. The sample size of the Christmas sample was based on 1990 Census data (2,000 children in the county under 10 years old). To get 90% con?dence the sample needed to contain 238 children. The sample that was obtained contained 268 children from 129 households. 20 The sampling method that was used consisted of: Identi?cation of the geographic area of interest; (Wilcox County) Identi?cation of the age group of interest; (Children under 10 years) Random selection of 42 sites, using a map of the area (clusters of homes denoted by a town, a school, a church, or a road were pulled "from a hat (6 census tracts were prede?ned in the county; the populations of the census tracts determined the number of sites selected in each) Random selection of a starting point, "household" within each site;(by the interviewers upon arrival to the site) and Selection of 7 individuals of the appropriate age ?orn within each of the 42 sites. Selection began in the starting household and then continued to the next nearest household until the total number of individuals was obtained. All individuals of the appropriate age living in the last household falling into the sample were included, even if this meant including more than 7 individuals from a site (24,25). 21 TABLE I Christmas Sample Comparison of the Actual Number Sampled vs. the Weighted Sample Number of householdsmact Actual Out of total Weighted against census ghildm <10 am he ALBERTA 34 310 40 CAMDEN 43 412 49 COY-FATAMA 25 134 17 PINE APPLEIOAK HILL 23 182 23 PINE BLUFF 87 670 36 CAMDEN TOWN 51 384 53 Total 268 2092 268 22 The Q_uestionnaire. The household questionnaire that was used for this survey was based on a questionnaire used in Zaire, Africa for a similar purpose. After making the appropriate changes, the questionnaire was pretested in Lowndes County, a county bordering Wilcox on the west with similar demographics, to determine whether it was e?'ective. The pretest consisted of visiting homes and administering the questionnaire to the head of a household in a similar manner to that which would by used in Wilcox County. Following the administration phase the interviewers discussed the problems they had seen. Changes were made as needed before the questionnaire was administered in Vredenburgh and county-wide (Appendix I). Using this questionnaire, information about the household was gathered. This information included: household characteristics, child morbidity data, health care infonnatiou, water and sanitation information, and perceived needs. The protocol that was used to perform an individual household survey is shown in Figure 1. Data Analysis. To perform the data analysis of the household questionnaire data a Chi-square test with Yates' correction (28) was used to assess which variables appeared to be associated with enteric diseases (diarrhea and intestinal helminths). Furthermore, point and 95% interval estimates of' Odds Ratio (OR) were calculated to determine the magnitude of association between enteric diseases and other variables (29). 23 FIGURE 1 HOUSEHOLD QUESTIONNAIRE PROTOCAL ?v Approach household (knock on door} Go to next house NOT HOME +4 I Asktospeaktothehead of the household Inquire about children <10 years Introduce self&. eXplain purpose of survey Ask if willing to participate Administer questionnaire Thank NO NO 24 Health Care Provider Surveys All ?ve physicians, along with the two school nurses, the head nurse at the Health Department, and two nurse practitioners who work in the rural health centers participated in the Provider Survey. The methodology that was used to survey a provider consisted of the two researchers setting up an appointment with the provider. One of the researchers would administer the questionnaire while the other observed. The two researchers developed the Provider Questionnaire based upon the recommendations of Scrimshaw and Hurtado (3). This questionnaire (Appendix J) was protested on the Kellogg project nurse to be sure that the questions were clear and the correct information was being obtained. Basic information concerning the practice of the provider was obtained. Questions were also asked about prevalence of childhood morbidity, in particular questions about the diagnosis and treatment of enteric disease (diarrhea and intestinal parasites). Providers were then asked to discuss the biggest needs of the county and barriers to health care for the general population. Service Utilization Information and Client Information was then obtained from other clinic personnel, usually a clerk. Information in this section of the survey included: data about the practice, service statistics, and acceptable payment procedures. Finally observations were made by the researchers about the waiting room. Chart Audits Chart audits were performed at the each of the 4 rural clinics to determine the amount of enteric disease among patients under the age of 10. The information that was extracted from the charts included: date of birth, date of visit, sex, race, zip code, and diagnosis. The incidence of enteric disease for two of the clinics, Yellow Bluff and Pine Apple, was made available by the Rural Health Initiative out of Selma. However, at the 25 Vredenburgh and Alberta Clinics encounter forms for the 1991 ?scal year were gone through by hand by the two researchers. At the Alberta Health Center there was a very large percentage of children that had been treated for intestinal helminths. Because of this, each individual chart was reviewed to determine the method of diagnosis. The nurse-practitioner had identi?ed the cases using a rectal smear, but was no longer working in the area to explain her method in person. The method has been described in the literature (26, and is as follows: a small sample of stool from a digital rectal exam is mixed with water and the eggs are viewed under low power with intermediate objective (45X), the eggs can easily be identi?ed. The technique is at least as accurate, but not as sensitive, as more standard laboratory methods that concentrate the ova before microscopic examination. The intensity of infection correlates with the number of eggs per gram of stool (26). In this manner the presence or absence of the following intestinal nematodes may be determined: 1)Ascaris lumbricoides, 2)Trichuris trichuria, 3)Enterobius vermicularis, 4)hoolrwonn species, and 5)Strongyloides stercoralis (27). However, the past nurse practitioner at the Alberta health center recorded her results as being positive for roundworms or ?atworms. Stool Samples Reports from health care providers interviewed in Wilcox County along with the outcome of the chart audits performed at the rural health clinics indicated that gut helminth infections may be a health problem among children in the county. Interviews with the local health officials also indicated that many dwellings do not have sanitary sewerage disposal systems. Conditions for transmission of intestinal parasites were optimal. 26 To initiate the stool sample survey, health care practitioners at the four rural health clinics were contacted and asked to collect specimens from their patients. All four clinics consented. Then each clinic was visited and supplied with the necessary materials and directions for how to collect the specimens (Appendix K). All subjects under 10 who visited the four rural health clinics were be eligible to enter the study, regardless of the reason for the visit. Written consent was solicited from the parent or guardian of children under 7 years of age and from both the subject and the parent or guardian in older children. The study was explained by a physician, nurse practitioner, or nurse at each clinic. Each subject was provided with an opaque stool cup, a tongue depressor, and a sticker with their clinic record number, age, sex, zip code, and the date of the clinic visit. When the ?lled stool cup was returned to the clinic, a portion of the stool was mixed with 10% buffered formalin in a vial. The ?lled vials were collected intermittently by a School of Public Health faculty member. The contents were then analyzed in the Department of International Health laboratory using a simple ?otation method. . Approximately I gram of stool was thoroughly mixed with 15 milliliters saturated sodium nitrate and allowed to sit undisturbed for 10 minutes in a test tube ?lled to the top. A cover slip was then touched to the top of the inverted meniscus. This method concentrated any helminth ova present. Helminth ova were identi?ed using direct . microscopic examination. Positive results were returned to the health clinics, so the subject could be treated. Based upon the number of patients under 10 years who were seen at each clinic and with an estimated helminth prevalence of 5% and 95% con?dence limits of 3% it was estimated that the needed sample size was 211. 27 RESULTS and DISCUSSION Household Surveys The results of the household surveys ?'om both Vredenburgh and the Christmas sample were combined to form a County data set. These three sets of data in the form of ?'equencies describing the samples are described in Appendix L. The results are broken down into the following categories: physical characteristics of the household, characteristics of the residents, breastfeeding, childhood morbidity, health care, transportation, source of income, pets, water and sanitation, solid waste disposal, existing latrines and septic tanks, interest in building a septic tank or latrine, and observations. According to our survey, 23.3% of the households sampled in Vredenburgh are without water in the house, 11% in the Christmas sample. The number of residents per household was found to be quite high with over 6 per household in Vredenburgh and nearly 5.5 in the Christmas sample. Both samples consisted of a higher percentage of nonwhite households than the county on the whole. In Vredenburgh this was because only the Quarter was sampled. There are between 1% and 7% of the households that are without a regular source of medical care. Approximately 66% of the households are on Medicaid, 16 have private insurance, and 17% paid individually for the health care of their children. About 17% of the households in Vredenburgh and 12% of the households in the Christmas sample do not have a standard indoor toilet. Approximately 35% of the County sample use a method other than a sewer system or a septic tank to dispose of waste; 16% pipe their sewage out onto the ground near their home, 20% use a cesspool or some other means of disposal. Of those households that use septic tanks, 76% were not working in Vredenburgh and 23% were not working in the Christmas sample. Sixty-nine percent of the households surveyed perceived their existing toilet facilities as a problem. Of those households that had inadequate sewage disposal, 70% expressed an interest in building a 28 latrine, a septic tank, or both ifsomeone were available to help them put in a low-cost facility. From the Vredenburgh survey 18.6% of the children were found to have had diarrhea in the last month; 6.3% from the Christmas survey. The results of the questionnaires for the children who had diarrhea in the last month were also analyzed separately and are described in Appendix M. According to these results, a large portion of the children with diarrhea were found in the Camden census tract. Interestingly, nearly all of these children were found to have water in the house and a working indoor toilet. In Vredenburgh, 54% of these children who had diarrhea were on the public sewer; but 46% piped their sewage into the yard or used some other means. In the Christmas sample 77% used either public sewer or a septic tank; 6% piped sewage into the yard; and 17% used another means. Sixty-seven percent of those in Vredenburgh and 44% of those in the rest of the county perceived their toilet facilities to be a problem. In the Vredenburgh data set when the cases and controls are looked at in relationship to city sewer vs. inadequate sewage disposal in a 2x2 Chi-square table, the Odds ratio=6 and the 95% Con?dence Interval=(1 .74-20.66) with a p<.05 (Figure 2). Table 2 describes the children sampled in Vredenburgh. The cases are the children who had an enteric disease, either diarrhea or intestinal parasites, in the last month or six months respectively. The controls are the children who had not had an enteric disease during the prescribed time. The sample consists of relatively young children, with an average age of approximately three years among both cases and controls. The mean number of children in the home under the age often is signi?cantly lower for the cases, as is the mean number of total residents. The mean age and education of the caretaker are almost identical for the two groups. The socioeconomic characteristics of this study population are lower than for the county on the whole (more households on social welfare and fewer working). The cases are less likely to be on city sewer and more likely to pipe sewage into the yard thus increasing exposure to enteric pathogens. However, cases are 29 more likely to have a water source and toilet in the house. Indoor plumbing should not increase exposure to enteric pathogens, unless local contamination of piped water is a problem. The cases also have more problems with mice, rats, and roaches, and they are more liker to have an inadequate means of solid waste disposal. These factors may not directly increase exposure to enteric pathogens, but for social and economic reasons may be more corru'non in households where such exposure is increased for other reasons. Table 3 describes the children sampled in the Christmas survey. The de?nition for cases and controls is the same as in Table 2. Camden town, shows a higher percentage of cases than did the other areas sampled. The mean age of cases and controls is between 3 and 5 years. The mean number of children under 10 in the home and the mean number of residents is lower for the cases than the controls. The mean age and education of the caretaker are similar for both the cases and the controls. Fifteen percent of the white children are cases compared with only 7% of black children. The socioeconomic characteristics are similar for the two groups and right on target for the county overall. In this survey the cases are less likely to have a problem with pests, less likely to have an inadequate form of sewerage disposal, and less likely to have an inadequate form of solid waste disposal. These ?ndings differ from the Vredenburgh sample. The cases in the Christmas sample were also more likely to have a toilet in the house and city water in the house than were the participants in the Vredenburgh sample. Tables 4, 5, and 6 summarize the results of the statistical analysis between major variables and enteric disease for the County as a whole and for the Vredenburgh and Christmas data sets, respectively. In the County data set, the only statistically signi?cant items are: more than ?ve children under the age often in the household and more than six residents in the household. It is possible that these two variables are signi?cant due to the increased likelihood of transmission among children or to increased transmission due to crowding. Trends were seen linking the risk of enteric disease to the absence of running water (a well-known risk factor for person-to?person transmission of enteric pathogens), 30 the absence of a standard indoor toilet, and the presence of ?ies (which can serve as vectors for enteric pathogens), in the home. It is interesting to note that, although children under 3 are normally at greater risk for enteric disease this was not the case in this survey. Also, although the presence of animals in the home or yard where children play o?en serves as a reservoir for certain pathogens such conditions were not seen as signi?cant in this case. In the Vredenburgh data set, the statistically signi?cant item was: family not owning their home. This could be due to the family not willing to invest in improvement of a home that is not theirs (eg. improved sewage disposal). In the Christmas data set, there were no statistically signi?cant items. 31 FIGURE 2 VREDENBURGH SURVEY 2x2 TABLE CHI-SQUARE Enteric Disease Euteric Disease - Wilcox County exposure (no sewer) 6 7 a Monroe County - exposure (sewer) 7 Odds Ratio 6 95% CJ. (1.74-20.66) p<.05 32 Comparison of Socioeconomic, Demographic, Characteristics of Cases and Controls in Vredenburgh Survey Variable Mean Age in Months (5.13.) Mean Number of Children <10 in home Mean Number of Residents in home Mean Age ofCaretaker in (S.D.) Mean Education of Caretaker Family's Income Aid for Dependent Children Food Stamps Work Fondly Oasis Home Telephone in home Washer in home Animals/Pests Animals in House Animals in Yard Problem with Flies Problem with Micev'RaLs Problem with Roaches Type of Sewerage Disposal City Sewer Non-ftmetioning Septic Piped into Yard Other Inadequate Sewerage Disposal Toilet in Home Water Source in Home City Water TABLE 2 Cases (children w! enteric disease) 33.7? (23.2) 2.77 6.15 34.38 (6.4) 10.46 l?L?c?d 13 13 13 33 (Va) 61.5 84.6 46.2 34.6 46.2 76.9 7.7 34.6 15.4 76.9 92.3 53.8 38.5 7.7 46.2 100 100 10-0 and Environmental Controls (children without enteric disease] 37.79 (29.9} 3.65 7.11 33.30 (9.6) 10.mail?h 16 43 41 73.7 39.5 36.8 52.6 24.6 43.9 7.0 73.7 26.3 54.4 35.0 71.9 1.3 12.3 14 28.1 75.4 71.9 100 Inadequate Solid Waste Disposal Mean Cleanliness of Interior Mean Cleanliness of Yard (S.D.) 3 2.38 2.85 (1.5) 34 23.1 5 2.31 3.33 8.3 TABLE 3 Comparison of Socioeconomic, Demographic, and Environmental Characteristics of Cases and Controls Variable Census Tract: Alberta Camden District Coy-Fatama Pine Appleank Hill Pine Hiilf?fellow Bluff Camden town Mean Age in Months (S.D.) Mean Number of Children <10 in home Mean Number of Residents in home Mean Age of Caretaker in yrs. (S.D.) Mean Education of Caretaker Race White Nonwhite Family's Income: Aid to Dependent Children Food Stamps Watking Family Owns Home Telephone in Home Washer in Home Dryer in Home Animalsa'Pests: Animals in House Animals in Yard Problem with Flies Problem with N?cefRats Problem with Roaches in Christmas Survey Cases {children with enteric disease) 1 4.5 5 22.7 2 9.1 4.5 4 18.2 9 40.9 58.41 (26.6) 2 4.82 36.77 (11.4) 11.09 6 27.3 16 72.7 12 54.5 14 63.6 11 50.0 12 54.5 16 72.7 13 59.1 8 36.4 5 22.7 21 95.5 4 18.2 6 27.3 1] 50.0 35 Controls (children without enteric disease40.86 {28.7) 2.77 6.17 36.31 (14.1) 11.20 33 209' 112 160 [29 1'152 12%) 12.0 12.8 9.5 9.1 34.3 17.4 13.6 86.4 46.3 66.1 53.3 71.5 61.6 64.9 29.3 26.0 91.3 34.7 37.6 62.3 Type of Sewerage Disposal: City Sewer Functioning Septic Nenmne?oning Septic Piped into Yard Other Inadequate Sewerage Disposal Toilet in Home Water City Well Other Water Source in Home Inadequate Solid Waste Disposal Mean Cleanliness of Interior (S.D.) Mean Cleanliness of Yard (S.D.) un?wqm 2.07 2.68 (1.2) 36 27.3 31.8 13.6 4.5 22.7 40.9 90.9 77.3 18.2 4.5 90.9 132.40 (1.2) 3.13 (1.2) 18.6 32.2 9.9 19.0 20.2 49.2 36.4 67.4 28.9 3.7 38.0 23.8 TABLE 4 County Data Set Association Between Major Variables and Enteric Diseases OR (95% (2.1.) P-value A. Household Characteristics 1. Race Non white 0.600 (.233, 1.540) .288 2. Absence of dryer 1.090 (.474, 2.507) .839 3. Absence ofteicphone 0.708 (.344, 1.456) .348 4. Don'town home 0.906 (.433, 1.899) .795 5. Number ofchildren <10 1 child 0.556 (.219, 1.410) .216 3 children 0.370 (.143, .960) .041 4 children 0.261 (.063, 1.093) .066 .235 children 0.156 (.041, .596) .007 6. Age of child <2 6 months 0.607 (.062, 5.937) .668 6-11 months 0.538 (.138, 2.103) .373 24-35 months 0.919 (.211, 4.001) .910 36-47 months 1.317 (.336, 5.602) .660 48-69 months 0.850 (.174, 4.149) .841 60-71 months 1.466 (.358, 5.997) .595 72-83 months 1.889 (.486, 7.340) .358 7. Age of caretaker . 25-29 years 0.262 (.038, 1.817) .175 40-49 years 0.921 (.314, 2.695) . .880 50-59 years 0.592 (.129, 2.728) .502 3; 60 years 0.524 (.115, 2.379) .403 8. Education of caretaker 9th grade 1.333 (.439, 4.048) .612 9th -111h grade 1.752 (.755, 4.065) .191 312111 grade 1.804 (.632, 5.147) .270 9. Number of residents per household 4-5 residents .458 (.169, 1.237) .124 6-7 residents .217 (.071, .662) .007 3 8 residents .253 (.085, .755) .014 B. Household Income 1. ADC Recipients 1.255 (.619, 2.545) .528 2. Food Stamp Recipients 1.043 (.480, 2.264) .916 3. Absence of work income 1.066 (.529, 2.150) .858 37 C. Wagew?Sanitation 1. Absence of running water in house 2. Watersource Well water Other 3. Inadequate sewage disposal 4. Absence of standard indoor toilet 5. Type of sewage disposal Septic system (?mctioning) Septic system (nonfunctioning) Piped into yard 0111:: (cesspool, Ian-inc, etc.) 6. inadequate solid waste disposal D. nimals Pests 1. Animals in house 2. Animals in yard 3. Roaches in house 4. Flies in house 5. Mw'Rats around house E. Observation 1. Very unclean yard 2. Very unclean interior of house 0. 342 0.419 0.815 0.911 0.325 0.594 0.794 0.749 0.696 1.053 0.716 1.460 0.934 0.413 1.222 0.294 0.859 38 (.034, 1.339) (.147, 1.198) (.100, 6.663) (.449, 1.850) (.031, 1.310) (.227, 1.556) (.209, 3.016) (.263, 2.091) (.250, 1.930) (.433, 2.530) (2.36, 1.794) (.422, 4.939) (.446, 1.953) (172,101?) (.504, 2.420) (.075, 1.150) (.171, 4.314) .133 .104 .849 .797 .114 .239 .735 .581 .488 .909 .426 .546 .853 .055 .577 .079 .853 TABLE 5 Vredenburgh Data Set Association Between Major Variables and Enteric Diseases A. seh ld Ch raeteristies 1. Absence of telephone 2. Don?t own home B. Household Income 1. ADC Recipients 2. Food Stamp Recipients 3. Lack ofwork income Q. WaterISgnita?on Inadequate sewage disposal D. Animal; J: Pests 1. Animals in house 2. Animals in yard 3. Roaches in house 4. Flies in house 5. ?nalists around house OR 0.330 4.950 0.571 0.647 0.631 0.455 1.104 1.964 1.959 0.509 2.796 39 (95% ca.) (.111, 1.293) (1.110, 22.065) (.62, 2.020) (.115, 3.649) (.201, 2.307} (134,1.551} (.111, 10.956) (.394, 9.7971 (.227, 16.377} (.102, 2.539) (.715, 10.930) P?value . 123 .036 .385 .622 .537 .208 .933 .410 .540 .410 .139 A. Hggsehgld Characteristics 1. Race Non white 2. Absence ofDryer 3. Absence of telephcme 4. Don?t own home B. Eggsehold Income 1. ADC Recipients 2. Food Starnp Recipients 3. Lackofwork income C. 1. Inadequate savage disposal 2. Absence of standard indoor toilet 3. Abseneeof runningwaterinhouse D, Animals Pest; 1. Animals in house 2. Animals in yard 3. Roaches in house h. . Flies in house 5. Moe?Rats around house TABLE 6 Christmas Data Set Association Between Major Variables and Enteric Diseases 0R 0.421 0.741 0.601 0.479 1.393 0.89? 1.142 1.39".ll 0.633 0.734 0.836 1.995 0.592 0.418 0.622 40 (95% CI.) (.157, 1.127) (.298, 1.842) (.229, 1.530) (.200, 1.143) (5111,3341) (.351, 2.223) (.476, 2.736} (.537, 3.386) (1113,2310) (.1154, 3.298) (.296, 2.361) (.265, 15.052} (.248, 1.413) (.141, 1.241) (.236, 1.633) P-value .085 .519 .302 .09? .458 .815 .767 .459 .548 .687 .735 .503 .237 .116 .337 Health Care Provider Surveys The results of the provider surveys are described in Table 7. Seventy percent of the respondents have worked in Wilcox County for at least ?ve years. The most common childhood illnesses they report seeing are: upper respiratory infections, skin infections, nutrition-related illnesses (failure to thrive, iron-de?ciency anemia, etc.), ear infections, and diarrhea. In rating conditions according to their prevalence on a ?ve point scale diarrhea was rated 2.75 (average to high prevalence); intestinal parasite infection 2.33 (average to high);and acute respiratory infection 1.69 (high to very high). These providers cited the major causes of diarrhea as viral, poor water supply, poor sanitation, unsanitary living conditions, poor personal hygiene, daycare, antibiotics, food poisoning, and allergic reactions. The treatments they recommend most often are clear liquids for 24 hours, Imodium, Kaopectate, or Pedialite. The major intestinal parasites that they report seeing are Ascaris and pinworms. About one half of the providers report that they run tests to con?rm their diagnosis. Vermox is the most common treatment used. The age grOup that they report is the most susceptible to diarrhea andfor intestinal parasites is 10 years. The most common time of year for these enteric diseases is summer. Communities that were mentioned as having higher prevalences of these conditions include: Alberta, Boykin, Pine Hill, and Vredenburgh. The average number of patient visits in each of these health care facilities in 199] was approximately 5,000 ranging from 1,802 to nearly 10,000. All of the providers felt strongly about making health care as accessible to their patients as possible. All of the health care providers accept Medicaid and uninsured clients. The 4 rural health centers, the Health Department, and Dr. Nettles have sliding fee scales for there patients. All the providers accept walk-ins as well as scheduled appointments. Many of the providers have of?ce hours after 5:00 pm. and on weekends. 41 These health providers reported that on average 33% of their clients are uninsured ranging for Syn-56%; 39% are covered by Medicaid ranging from 15% to 75%; 13% are covered by Medicare ranging from 3% to 24%; and 14% are insured ranging from 4% to 25%. Two of the rural health clinics reported that 90-93% of their patients are living at or below the federal poverty level. The providers identi?ed poverty and poor education as the two biggest problems facing Wllcox County. They felt that the greatest barriers to health care were poverty, lack of transportation, and ignorance. Dr. Cook identi?ed the biggest problems of her patients associated with the poverty as the nutritional problems. "Poor people eat cheaper food which includes many fatty and high salt items that add to blood pressure and diabetes problems (Appendix 42 Table 7 Results of the Provider Surveys Job litlefposilion Doctor Nurse Practitioner Nurse School Nurse White Non white Male Female Number of years working in county 1 year 1- wears 5-10 years 10-20 years >20 years Where wort: Private practice Rural Clinic Health Department Schools Hospital services provided Pediatric eare Immunizations Prenatal care Family Planning Most common childhood illnesses seen (1 provider did not answer) Upper Respiratory Infections Skin Infections Nutrition-related illnesses Ear Infections Diarrhea Intestinal Parasites Seizures Asthma Injuries (100%) 7 3 10 (100%) 8. Prevalence of following conditions (Ranked on 1-5 scale. l=very high, 3= average, 5=very low) Diarrhea 2.75 (average-high) Intestinal Parasites 2.33 (average-high) Acute Respiratory Infections 1.69 (high-very high) Scabies 3.63 (average-low) Conjunctivitis 3.75 (average-low) Lead Poisoning 4.38 (low-very low) 9. De?nition of diarrhea from clinical perspective liquid runny stools 4 >5 watery stoolfday 2 6-8 loose stoolsfday 1 watery stool; l/hour 1 10. Major causes of diarrhea Viral 4 Poor water supply 1 Poor sanitation 2 Unsanitary living conditions 1 Poor personal hygiene 1 Daycare (focal-oral transmission) 1 Antibiotics 1 Food poisoning 1 Allergic reactions 1 11. Major intestinal parasites Ascaris 6 Pinwortns Hookworms 3 Tape worms 2 None I 12. Tests run to con?rm diagnosis of intestinal worms YES 4 NO 5 13. Treatment for diarrhea Clear liquids for 24 hours 3 [medium 2 Kaopectate Pediaiite or equivalent 1 (l Refer to physician 3 14. Treatment for intestinal parasites Venues 4 Antiminth (if insured) 1 Piperazine 1 Refer to physician 2 44 15. 16. 17. 18. 19. 20. 203. 21. 22. Recommend home treatment of diarrhea YES 8 (100%) (forcing ?uids, pepto bisrnal most common Rx recommended) N0 When diarrhea becomes serious enough to seek treatment in a health care facility After 24 hours Dehydration How often are children hospitalized for dehydration (5-point scale; l=very often 5=neven Deaths associated with dehydration None Age group most susceptible to diarrhea andfor intestinal parasites 6 years 6 months to 8 years 2-10 years No particular Susana] variation in these conditions YES NO When most common Summer FallfWinler with higher prevalences of these conditions Alberta Boykin Pine Hill Low income, poor sewage No Biggest problems facing Wilcox County Povert)r Poor education Lack of access to health care (5) HIV No transportation Teenage Pregnancy Low parental involvement in health dc education 45 0 3 5 3.33 (seldom) 7 (10023. Barriers to health care Money Transportation Ignorance Unconeemed parents Too few doctors None Chart Audits The results of the chart audits to determine the incidence of enteric disease among children at the four rural health clinics are as follows. At the Yellow Bluff Clinic the incidence of enteric disease diagnoses in children under 12 'during 1991 were 1.4% with gastroenteritis and 0.7% with intestinal helminths. At the Pine Apple Clinic the incidence of enteric disease diagnoses in children under 12 during 1991 were 2.6% with diarrhea or gastroenteritis and 1.6 with intestinal helminths. At the Vredenburgh Clinic the incidence of enteric disease in children under 10 during the ?scal year 1991-1992 were 2.5% with diarrhea, 3.3% with gastritis, and 5.0% with intestinal parasites. At the Alberta Clinic the incidence of enteric disease in children under 10 during the ?scal year 1991- 1992 were 9.5% with gastroenteritis and 33.7% with intestinal helminths. Because of the extraordinarily high rate of intestinal heiminths found at the Alberta Clinic during the original chart audit, a follow- up audit was conducted to determine the number of cases that had been diagnosed based on a positive laboratory test (Appendix N). The results of the original chart audit had identi?ed 120 children who had been diagnosed with and treated for intestinal helminths during the 1991-1992 ?scal year. A very signi?ch portion of these children (117 out of 120 or 97.5%) who were treated for helminths had tested positive at least once during the year with a rectal smear performed in the of?ce (procedure described). Thirty-one of these children had tested positive for helminths more than once during the study period. One hundred and ?fty-two cases of helminths were treated following a positive rectal smear. Fourteen cases were treated without a positive test. These cases were based on mother's wishes, or the actual passing or vomiting a worm. J. Paul Jones Hospital, the county hospital's inpatient admissions of children under 12 during 1991 showed that 12.5% of admissions for this age group were for dehydration, 4.2% were for diarrhea, and 1.4% were for intestinal parasites. 47 Stool Samples A total of 81 samples were collected and analyzed. The clinics distributed the cups to obtain samples, however, there was a very low return rate. Thirty-nine stool samples were analyzed from the Alberta Clinic with 2 showing up positive for ascaris. Nine were analyzed from the Pine Apple Clinic with 0 positives. Twenty-six were analyzed from the Vredenburgh Clinic with 0 positives, however, one roundworm, ascaris, was brought in. Seven stool samples were analyzed for the Yellow Blu?? Clinic with 0 positives. The rate of positives for Ascaris at the Alberta Clinic is The rate for the all the clinics combined is Although the rate at the Alberta Clinic is not as high as what was seen in the chart audit data it is signi?cantly higher than the rate seen for Alabama according to the state diagnostic laboratory in 1987. And it is higher than the national percentage of positives for Ascarr?s seen in that same study (31). In a chart review of the 39 subjects from the Alberta Clinic that were included in the stool sample survey 37 charts were pulled; 2 of the charts were missing. Fourteen children had he recorded medical history of intestinal helminths prior to the survey. Eleven of the subjects (3 had tested positive for intestinal helminths in the last year. Eleven subjects (30 had been treated for intestinal helminths in the last year. Twenty- one of the subjects have tested positive for intestinal helminths at some timein the past. Nineteen of the subjects have been treated at some time in the past. Twelve of the subjects have history's of multiple helminth infections. Of the three subjects who tested positive in the stool sample survey, two had history's of a helminth infection; one in 1987 and the other in 1991. Collection of stool specimens may be especially dif?cult among the pediatric age group. This is signi?cant because it is this age group that has the highest risk of harboring intestinal parasites. These factors may lead to poor patient cooperation, increased physician frustration, and deereased diagnosis of intestinal parasites. This may result in a 48 tendency for the physician to treat patients without a Speci?c diagnosis (27). Many of the health care providers in the area based treatment of intestinal parasites on the suspicion of the parent rather than a positive diagnostic test. 49 CONCLUSIONS AND RECOMMENQATIONS FOR PROGRAMS AND FUTURE RESEARCH Based on this Needs Assessment the major health-related problems in Wilcox County include: wideSpread poverty and unemployment, poor housing conditions, a lack of transportation, a weak public school system, a lack of access to prenatal care and delivery services, and a serious lack of an adequate water supply, plumbing, and sewage disposal methods. The Household Surveys determined that 15% of households do not have a standard indoor toilet; 35% use some method other than public sewer or septic system for sewerage disposal with 16% piping sewage out onto the ground near the house; and 69% see existing toilet facilities as a problem. In Vredenburgh, a signi?cant relationship was seen between enteric diseases in children under 10 and inadequate sewage disposal The health care providers cited amongst the major causes of diarrhea: poor water supply, poor sanitation, unsanitary living conditions, and poor personal hygiene. And they categorized the prevalence of enteric disease in young children as average to high. The age group they consider to be the most susceptible is children less than 10 years old. Speci?c communities that they identi?ed as having an excess of enteric disease are Alberta, Boylcin, Pine Hill, and Vredenburgh. These are the same communities that the county sanitarian pointed out as problem areas. The chart audit survey revealed an excess of enteric disease; particularly in the northwest portion of the county. At the Alberta Clinic 33.7% of patients under 10 years old seen during the 1991-1992 ?scal year were diagnosed with intestinal helminths. Suggested interventions for the county include: development of? a health education curriculum for the schools focusing on nutrition and hygiene, a pilot project using intermediate technology to remedy the sewage disposal problems; and continuing education for the health care providers focusing on diagnosis and treatment of enteric disease. 50 Since enteric diseases and nutrition-related illnesses (especially hypertension and diabetes) are some of the most common seen, a health education curriculum tailored to the needs of the teachers in the Wilcox County public school system could meet many needs. It should be integrated into the regular subjects, serving to complement the skills that are already being taught. A lunch room component would de?nitely have some additional impact since 92% of the students are on the Rec or reduced lunch program. Focusing on behavior changes in the areas of personal hygiene and nutrition, especially in the lower grades could potentially have some long-term effects in the county. Trial interventions with intermediate technology to help remedy the sanitation problems should be undertaken in the county. These will include: 1) development and trial of physical methods to improve sanitary waste disposal and supply safe water in the house; 2) providing directed messages on health education aimed at reducing the spread of fecal- orally transmitted disease among household members; 3) raising community awareness of the inter?family nature of and mode of spread of this group of diseases; and 4) promoting community hygiene practices aimed at disrupting the fecal-oral cycle for diarrhea and intestinal parasites. SIFAT, (Serving In Faith And Technology or the Southern Institute For Appropriate Technology), is a training site for missionaries prior to serving overseas and foreign nationals. It is located in Lineville, Alabama where appropriate technology intended for use in the Third World is set up and tested. They should be accessed for assistance with setting up the demonstration project. They have already had some interaction with the county through the outreach workers in the Vredenburgh area. Acute gastroenteritis is the leading cause of death worldwide in children under 4 years of age, as well as the second most common nonsurgical reason for pediatric admission to hospitals in the industrialized nations. The advent of oral glucose-electrolyte solutions in the last 25 years has revolutionized the treatment of dehydration that is secondary to acute diarrheal illnesses (30). Despite the wealth of accumulated knowledge, 51 pediatricians experience with oral rehydration in the United States is limited. Wilcox County could serve as a good place to offer some continuing education on Oral Rehydration Therapy to the physicians and study the outcomes. Future research should include: looking at the prenatal care and pregnancy outcomes of women in Wilcox County following the implementation of the Medicaid Waiver; studying the constructed wetland project at the elementary school in Pine Apple to determine whether it may be a practical solution to some of the sanitation problems in this region of Alabama; and following up of the sanitation pilot project to determine whether the use of intermediate technologies is a feasible solution to the lack of adequate sanitation and using this information to institute policy change at the state level. The effects of the newly instituted Medicaid Waiver on prenatal care and birth outcomes in the county should be monitored closely. Wilcox County has some of the poorest indicators for pregnancy and birth outcomes in the state; 62.3% of children are born to unmarried women, 22.9% of births are to teens, and 11.7% of babies born are low birth weight. Prior to the passage of the Medicaid Waiver, 47.8% of pregnant women were not getting adequate prenatal care. At that time they were able to receive care at any of the health care providers. Since the Wilcox County Health Department located in Camden has recently become the preferred provider for Medicaid reimbursement, and since there is such a gross lack of transportation amongst the poor many providers fear that now many more of their patients may not get adequate prenatal care. The constructed wetlands recently installed as the primary sewage treatment and disposal method for WJ. Jones Elementary School in Pine Apple is an example of alternative technology. This system should be monitored closely and successes and failures should be documented Since a large number of Alabama residents are not served by public sewer systems and failed septic systems are relatively common due to the problems with adequate percolation and low lying areas, the wetlands may be a sewage disposal system very much suited to the needs of this region and the state. 52 Technology for sewage treatment and disposal used in the developing world, while far from perfect, provides improvement over direct discharge into yards and areas where children play and attend school. If use of these systems were permitted in Wilcox County, even on a temporary basis, some reduction of enteric disease would be expected. Success with one or more interventions in the pilot test program mentioned earlier could be used as the basis to develop several demonstration projects in selected communities. Use of many of these systems in the United States would represent a departure from the sanitary code of most states. Thus, the physical interventions that might be incorporated into demonstration projects would have to be coordinated, and approved by the local and state health departments before this technology could be used. If success?il, the precedent could be established for instituting policy changes in the sanitary codes, potentially bene?ting many areas where the lack of adequate sewage disposal is related to poverty. 53 APPENDICES 54 APPENDIX A Resource: (5) Table 3.?Postneonatal Dianneel Mortality in the United States. 1973 Through 1983' Whltu Tot-l Toul No. of Mortality No. of Horullty Region Dull-u Flair Death: Roto' Northeast 319 5.5 215 21.1 North-Central 531 6.4 326 2B. 9 50th 936 10.3 1141 39.1 West 521 9.4 96 2&5 233'! 3.2 171'! 32.2 'Morulmr rate is me numoer of dismal} deaths orhong infants aged 1 throth 11 months per 100000 live births. TTwo hundred tour deaths in other rrLinority groups are not holuded. Fig 3.?F?ostneonatal inlant mortality associated with diarrhea. by state. 1973 to 1583. Mortality rate is calculated as number at deaths among intents aged 1 to 11 months per 100 000 the births and is shawn as lollows: open areas indicate less than 5; horizontally slashed areas. five to nine; verticalry slashed areas. ten to and meshatched areas. 15 or more." Table d.?Postneonatal Diarrheal Mortality' in 1950 Birth Cohort Birth Wot-uh! a 22590 . Region wntu Black White Bust: Northeast 12.5 58.6 1.4 7.13 North-Central 24.1 39.4 {1.5 4.3 soth 42 9 39.5 2.9 13.1r west 32.6 2.3 2.1 Total 30.1 1'16 La 6.1 ?Mortality rate is the number or diarrhea! deaths per 100000 postnoonomt survivors. Ema are from the National lnlant Mortality Surveillance project. APPENDIX Resource: (32) MAP OF AIABAMA PUBLIC HEALTH AREAS AND COUNTIES LAUUEHDILE LIMESYDHE HADISDH JACKSON HAHSHAL HARICIH WINSTON CULLHAH EEURNE HAHDD LPH ALLAPCBSA ww- EULLUCK amnaua I 5 mus CLARKE HENRY w: - VA . 56 APPENDIX Resource: 13) 10. 11. 12. 13. 14. WILCOX COUNTY FACT SHEET Based on 1990 Census Data Population 1990 - 13,563 Under 5 1,075 Under 18 4,612 18?64 6,810 65 and over 2,146 Racial Breakdown - 31% white, 69% nonwhite State - 74% white, 26% nonwhite Total Live Births 1990 249 Crude Birth Rate - 18.4l1,000 population State - Births to Unmarried Women 62.3% State - 30.1% Births to Teens - 22.9% State - 18.2% Low Birth Weight Rate - 11.7% State 8.4% Without Adequate Prenatal Care - 47.8% State - 33.5% Crude Death Rate - population State 9.711.000 Physicians 5 population) Hospital Beds State - population Medicaid Eligible 34.7% State 11.9% Per capita Income 6,552 State $11,486 Poverty: Families Below Poverty Level - 39.3% State 14.3% Under 18 Below Poverty Level - 57.4% State 24.0% 57 15. 16. 17. 18. 19. Female?Headed Households - 31% - State 22% Unemployment Rate - 14.3% State 6.9% High School Graduation Rate - 51.8% State - 66.8% Public School Lunch Program Participation Free - 89% Reduced 3% Paid - 8% Plumbing: 5,119 Housing Units in the County Lack complete indoor plumbing - 11.0% On City Water - 63.5% State - 87.1% On Public Sewer 23.5% State - 54.5% Lack Kitchen Facilities - 8.4% State 1.3% 53 APPENDIX (continued) 1990 PROFILE OF ALABAMA 1330 CENSUS POPULATION NATALITY MORTALITY Total: 4,040.55? 1111.11 leo Births: 03.420 Total 00:01:: 39.335 2.975.192 Tonnage Molhars: 11.552 Want Deaths: 559 Black 51 01116? 1.034.790 Unmarrind 19,059 Poxtnaunltal Deaths: 223 Rank Among Countiu: Low Weight Binhs: 5,331 Nuanarll maths: 41.11 53'4"" Mil?: 25.0 Mudiln Ago of Mother: 25 Parinltal Duathl.? 221 Madian Age: 33.0 MAREIAGEIDIVOHCE Fatal Deaths: 550 Marriages: 43.050 Dissoluuans: 25.575 NATALITY ALL BIRTHS BIRTHS TO TEENAGE MOTHERS Total ?VI-lite Black 2. Ethan Total White Black 31 Other ND. Flat: Nu. Flat: No. Rain Na. Rate No. Hutu Nu. Ru. Live Births 63.420 15.? 41.022 13.3 22.343 21.0 Liva Binhs 11.552 3?.5 5.905 29.5 5,647 54.3 No. Ratio No. Ratio No. Ruin NO. Flltia No. Ratio Ho. Fiatia Unmarriad Mothers 13.093 301.2 4.302 115.4 14.137 635.3 Unmarriad Mathars 2.233 531.0 2.032 344.1 5,257 030.0 Low Waight 5.331 34.1 2.545 52.0 2.735 124.? Low Weight 1.231 105.5 45E- 7'25 133.2 NoTirlm ur 1.000 pontluiln and mi. Hr 1.110011" um. I?y?cild gr?. MORTALITY Black and Black and Toial Mall Fll'nlii Whita Whit: Whit: Farnale Black and Dtl'lar Dthar Mil. 01h? Fgmale Daaths 33.335 20.555 13.6110 23.535 15.025 13.510 10.650 5.590 5.050 Mortality! Rate 9.7 10.7 3.9 9.5 10.4 3.3 10.0 11.4 3.3 An. In Yuan Undo: 1 1-4 5-9 10-14 15-13 20-24. 25-25 30-34 35-4-4 45-54 55-34 35-24 75+ Unk. Tutll Death: 633 1.24 3? 106 331 451 510 551 1,520 2,419 5,041 3.332 10.510 White Male 137? 43 33 40 151 213 219 221 500 1.052 2.311 3.553 5.001" Whit: Female 151 314 534 1.235 2.553 3.232 Black and Other Mlle 1'3? 33 21 30 30 1-4-4 150 157 332 461' 303 1.137 1.303 Blank and Other Female 154 214 336 541 1.035 2.440 NOTE: Han-in run a-Ir 1.000 wudstiun in Inning If?. INFANT AND FEEINATAL RELATED MORTALITY Hall in n-ar 100.000 pond-hm in arm. All Math-n Total White Buick and 01.11-1- Tolal Whit- Black and Dlhar Iniant Baths 533 333 351 111 34 Flat: par1.000 Live Births 10.3 3.2 15.:ll 14.3 13.0 16.5 Postnaanaral Deaths 223 105 123 51 25 25 Rate par 1.000 Uva Births 3.6 2.6 5.5 4.4 4.2 4.5 Hanna?! Daaths 461 233 223 120 52 EB Hate par 1.000 Liver Births 17.3 10.2 10.4 8.8 12.0 Perinatal Deaths 1'21 380 341 14? 5? 80 Hutu par 1.000 Daiivarias 11.3 9.2 15.2 12.7 11.3 14.1 Fatal Deaths 530 333 347 123 51 7? Ratio par 1.000 Liva Birth: 10.? 3.1 15.5 11.1 8.5 13.5 Matarnal Daatha 1O 5 Rate per 10,000 Liva Births 1.6 1.2 1.2 NOTE: Hui-chitin are hand In In: Inn!- in uni?ed erwa. Dlin?tm an in mm- dun- 0! 2a or more pn1l110n. LEADING CAUSES OF DEATH MARRIAGE Total mite Black and O?lhur NO. 01' Number Hate Number Rata Number Flat- Marriagaa Hula Disaasas 111' than Haan 12.393 313.1 5.773 323.6 3.115 305.2 Total 43.050 10.7 Malignant Nuuplasms 8.53? 215.2 6.485 217.9 2.212 215.? White 34.361 11.? Carubmns?lar Diseases 2.931 12.5 1.992 06.3 335 92.0 Black and Other 2.1139 Accident: 2.293 53.3 1.537 57.0 502 59.0 Hora; i. papuLIn-nnln ?Ham qmun. Chrunic Dbst. Pul. Dis. ?1 All. Cami. 1.504 37.2 1.237 43.3 20? 20.3 Pnaumonia and Influenza 1.258 31.1 970 32.6 233 2?.0 Diabataa Mallitus 350 21.0 50? 12.0 343 33.5 Numblr Diana-nu ot1ha Art-arias 706 1?.5 540 13.1 156 16-3 T?'t?l Dissolution 25.523 Homicide 552 13.5 207 7.0 3'55 34.3 Divorcus 25.513 All Othar Cauaas. Residual 7.635 1 39.0 5.212 125.1 2.423 227.5 Annulment: 155 Ram 5.4 NOTE: Fina in par 1.000 puma-11011. HOTEL 5- In Not-I Inlr?uthan I 51f uuw 1M and which 1: 01' plan: or occur-rum. Camp" .11qu In: "wall-H inm'nru mu wH:h NI duh-M Iran-r1 mull Mill-an a-r ta urn-AI non-Julianna. Hat-I d-uwI-d by 9991.. lmull gnu-11m me am.- n? 5.. "gm. 59 APPENDIX (continued) 1990 PROFILE OF WILCOX COUNTY 1990 CENSUS POPULATION NATALITT Total: 13.569 Tote! Live Births: 249 Total Deaths: 153 White: 11,203 Teenage Mothers: 57 Infant 1 Bleak 5t Other: 9,355 Unmarried Mothers: 15-5 Poatnaonatal Deaths: Hank Amen: Counties; 60 Low Weight Birthi: 25 Naonotal Deaths: 1 Per Equere Mile: 15.4 Median Age. at Mother: 24 Perinatai Deaths: 3 Median Age: 30.4 MARRIAGEIDWORCE Fatal Deaths: 5 105 Disaolutiona: 42 NATALITY ALL BIRTHS BIRTHS TO TEENAGE MOTHERS Tolel White Black at Other Total White Black 5. Other No. Ran Ne. Hate He. Rate No. Flata No. Rate No. Flata Live Birth: :49 15.11 I13 10.! 203 22.5 Litre Birth: 5? 4.2.5 11 15.4' 53 43.3 No. FlatIo No. Ratio No. Ratio NI. Relic Nu. Ratio No. Ratio Unmerr'ied Mother: 155 522.5 5 113.3. 1513 728.1 Unmarried Mothers 5.1- 9293 3 750.0' 50 943.4 Low Weight 29 116.5 1 23.3. 25 135.5 LOW Weight 3? 123.3 1 350.0' 113.2 HM- il per 1.0119 WIGM ant! felib par Lan In. huh hep-adri-tl grainy. MORTALITY Blank and Black end Total Male Fannie White Hlle White Fl?'llil Elack and Other Other Mela Either Fe male Deaths 153 .34 Mortality Rate 11.3 141.7 3.3 11.5 11.3 11.9 11.0 16.0 Fin-1n Yuan Undll'i 1-4 5-9 10-14 15-15 25?24 25-29 30?34 35-4-4 ?5?54 55-54 55-74 75+ Unit. Total Deaths 31' 1'5 White Male 1 1 E- 10 5 White Farnele 1 w? 1 2 16 Black and Other Male Black and Other Female 1 1 1 3 11' ?w MUTE.- hlanalin- ma nr 1.000 predation hl?em? are-tn. INFANT AND PERINATAL RELATED MORTALITY All Deaths Teenage Mother! Total W'hile Block and Ethel Total White Ind Other ?11.11! Daath: 1 ?l 1 1 Flete per 1,000 Live Birth: 4.0 23.3' 1?.5 250.0' Postnaonatal Dllti'll Flete per 1,000 Live Births Neonatal Death: 1 1 1 1 Rate per 1.000 Live Births 4.0 23.3' -- 17.5 150.0' Perinatal Death! 3- 1 2 1 1 Flate pnr1.000 Deliveries 12.0 23.3. 9.6 11.5 250.0' Feul Deaths 5 1 1 Ratio per 1.0130 Live Birth! 20.1 24.2 17.5 13.9 Matarnel Deaths -- Flete par 10.000 Live Births NOTE: Iauti?lalio are b?d enliv- birlha in ?lm. (Joli-uric: are live birth- plu fan! death: of 23 or more art-ab outer-on. LEADING CAUSES OF DEATH MARRIAGE Totei White Black and Other No. of Number Reta Numb-r Rate Numb-t Hate Marriage: Rate Dill-Ben 01 the Heart 45 353.5 11 251.? 385.1 Tote! 105 7.7 Malignant Neoplasm: 30 221.1 10 231.9 2t) 213.5 White 35 3.6 Pneumonia r. In?uenza 12 88.4 5 119.0 74.7 Black and Other 59 1.4 Cerebrovosouler Diseases 10 73.7 5 115.13 53.4 non,- nu. Loo-o popul-alun in ?um-d :muu. Accidents 10 13.1" 4 95.2 6 64.1 Homicide 3 22.1 3 32.0 DIVORCE Nephritie, Neph. Syn. a. Nephrosis 3 22.1 -- 3 32.0 Number Chronic Obit. Pul, Elle. 51 All. Cond. 2 14.7 2 21.4 Total Dissolution! 42 Diebetee Mellitua 2 14.? 2 21.4 Divorces 35 Chronic Linr and Cirrhosis 2 14.7 2 21.4 Annuiments 3 All other Causes. Residue! 31 223.5 15 355.9 1 5 'Fie'te 3.1 no?; im. I. panda-lion InciIi-d or?. NOTE: n-I- .- uI-r LOUD paw-nan. 5? [urn-Jul Hal-n at Simon. NJ II in ?lie-am for mention an! enforci- when I by elm e! ?cur-nae. Caution tit-add b- ung-m huh-q ?rim-t an darivod 'I?fl'l manual-I or candy Io when popular-en. ?au- damn-d by In apply It urn-fl paw-um the new Ml ha alabk. 60 APPENDIX (continued) 1991 PROFILE OF WELCOX COUNTY 1991 POPULATION NATALITY Total: 13.132 Total Litre Birth: 25? Total Deaths: Whitu: 11.232 Tour-ago Mothers: 65 lnlant Deaths: 5 Black 5: Clint: 9.500 Unmarried Mothers: 175 Postnoonatni Deaths: 1 Earth Among Counlios: 60 Low Woight Births: 25 Neonatal Dooths: 5 For Squaro Milo: 15.6 Median Ago at Mother: 23 Parinatnt Deaths: 3 Madian Ana: 30.4 MARRIAGEIDIUDRCE Fatal Deaths: 1 Marriagas: 24 Dissalutlons: 41 NATAUTY ALL BIRTHS BIRTHS TEENAGE MOTHERS Total White Blaolt It Othar Total Whit: Elaoit 3. Other NO. Rat! No. Rate No. Rota No. Flatt: No. Rats No. Rota Lin Bi?hl 257 19.4 42 9.9 225 23.? Liva Birth: 85 48.9 4 16.7' 61 55.0 No. Ratio No. Ratio Ho. Ratio N9. Ratio No. Ratio No. Moth?ll 125 620.4 1 23.5' 1?3 ?51.1. Unmarried Mother: SB 352.3 55 950.5 Low Waight 25 93.! 3 71,4" 22 37.3 Low Weight 92.3 6 98.4 NOTE: bull 1.000 pupil-lion uni ?ti. p-r LUOU 51' in gr?. MORTALITY Black and Black and Total Fomolt Whlto 'Nhitl Mala Whitn Fontan Black and Other Dthar Mill Oil-tor Farmle Duths 174 Mortality Hutu 12.? 14.5 11.11I 13.0 15.3 10.9 12.5 14.2 11.1 Ago In You: Under 1 1-4 5-9 15-15 20-24 25-29 30-34 35-4-4 45-54 55-64 65-24 25+ Unit. Total. Dulths White Mata 2 2 5 7 14 White Fomala 'l - 4 5 1r. Black and Dthor MaliBlack and Uthar Fomlla 1 1 2 2 11' 2E NOTE: Hart-tin- run it our 1.0M "Motion Ion-cilia! grotto. INFANT AND PERINATAL RELATED MORTALITY HOTEL Run in p-I-r nonunion uncut?d witnL ill- par 1.000- pendulum All Deaths Toonngl Mathari Total Mite Black and Dthor Total Whit- Blaak and Dtl?tlr Duths 6 1 5 Rate per 1.000 Live Births 22.5 23.8' 22.2 Postman-Ill Deaths 1 1 Rota per 1.00:! Live Birth: 4.4 Neonatal Booths 5 1 It Rita par1.00D Liver Births 18.7 23.8' 17.3 Perinatal Duluth: 2 1 2 par LEGO Dolivarins 11.2 23.3. 8.5 - Foul Deaths 1 1 Ratio par 1.000 Litre Birth: 23.8' Matarnol Duth: Rate per 10,000 Live Births -- -r I NOTE: Hut-Julio In bond on thr- birthr in Incitiod arm. Dulvcrin in tin It'lrtl?u mu: fclal dun- 51 23 gr no" wait. gnluiun, LEADING CAUSES OF DEATH Total Whit: Black Ind Other No. ol Number Rota Number Rota Number Rate Marriages Flatt: Disaasas of tho Haart 45 322.? 13 301.2 32 335.8 Total 2?4 5.4 Mali-grunt Naoolasms 29 211.2 10 236.3 15 IOOJD White Disoasaa 1 131.1 9 212.? 5 54.? Block and Other 3? 3.9 ACCid?nTl 17 1 2 15 15?.9 Inn in par 1.0% output-tim- in lp-l?lhld var-up. Diseases of tho Artorios 1' 51.0 3 20.3 4 42.1 Naphritis. Naph. syn. 5i Nophrosls 6 43.? 1 23.5 5 52.6 DIVORCE Diabetes Mallitus a 43.? 5 53.2 Numbgr Pnaumonin 5: Influenza 5 35.4 3 20.9 2 21.1 Total Dissolutions Homicide 5 36.41 5 52.6 Divoroas 41 All Dlhar Counts. Residual 36 252.2 14 330.3 22 231.5 Annulm'anta Rater 3.0 NOTE: 5H in Tush-hi "Ill- al Introduction sung-n. q?pg?n?. to, mung". gm w?gh .. of ?taunt cum? men? hut-Inn fltII which u- dlmrI-d Irv-m urn-ll ?It-n. .l 'Inl' duiokd a Mr ?1 ?aunt-Ina and mar-r not bu ntubls. 61 GENERAL HIGHWAY MAP WILCOX COUNTY Prepared by STATE OF ALABMIA HIGHWAY DEPT. BUREAU OF STATE PLANNEG US. DEPARTMENT OF TRANSPORTATION FEDERAL HIGHWAY ADMINISTRATION 1981 rpm!)ch Schoc? c) APPLNUM ll: APPENDIX Resource: (14) PERCENT OF POPULATION ELIGIBLE FOR MEDICAID FISCAL YEAR1991 3.95 ?.3305 10.3% Oprah What 9.01. 103% 10.8% Hum any- 11.2% 12.515 9.03; 9.55 Ilu'l 5.2? Lu- Ul'l-d - cum 3-511. gnu-n 10.3% 10.4% 15.1% in. 4.7% 9 8% 11.01. 1% 4 0'5 30.0% 13511, 13.5% B-I Ell-3% 10.9% run-u? I I aofa" 153* '1'5351. 8.1-1. Ill-m 212* 20.5% n? 20.13: m? 2555 13.5% 133% um 15755111 14.5% ?ll-n 17.55. 18.4% M- 9.51. Em . I 13.5% 11.11. 62 sup-r-? Wilcox. County chool systemic. woes are legion Board?s influence on hiring Tl i? like ?cronyism? to state board By Bill Plolt Fleas stall writer r? ?t'r'ilt'os County [fem Ira! Iligh School is one at ?it! most modern and atlraclrre schools in Alabama. The $15 million building. cont- plr-led three years ago. has a 25?mo- ir-r. Olympic?size indoor swimming not. an all-seat auditorium. 't'oca- lional lung with computer and other tabs. .1 modern gymnast-ant and a lir hrarr easily accessible to clustered classic-urns The sparkling. colored building replaces three rundourl high schools in the Black Belt county But the high school is an anomaly a system called one at the nets! in the state The system 5 problems were so serious that earlier this summer. at Ine request at state Supctintt'ndenl ol Education Wayne Teague. the 104 int Board at Education Super- intendent 5.15. L'ollier Tongue .1 Camden banker as cus- mrtran at lands and .1 Int trier Bullock 'Znurrtr school ollicral as acting su- The mares tell lms: short of a rumpletc takeover ol the slalom by Teague and the slate Department of Educ a lion Teague lashed out at a lael: of leadership in the systorrt. which he said is also The Wilcox County Board of Edu- cation lueled tlte long-running corr- lrorersy over the school system's leadership when it immediately re- lrired Collier as assistant superinten- dent ol education no change in salary and benetils. It then return-ed slate Hep. James Thomas as principal at lt'ilcos Con- trol High School. a position he had held since the school opened in IBM. although Teague has distanced himsell trom the Thomas situation, he made it clear that he was un- happy over the rehiring ol Collier, who received marlrs at ?ttnsatislae- tory" or "needs improvement" last spring in each of eight evaluation categories listed in a slate Board of Education report. Collier. who twice has been ac- cused of altering grades to the ad- vantage at his daughters. obvioust I'tas strung support from a maturity at board members. Although a lor- Superintendent naught to have him retrieved as princ' in one oi the incidents. the board protected 52min?. I .rr-E NEWE 509059? Wilcox County Central High library in Camden has skylights. paneled ceilings. cos Central position. in over the objections oi Chit-II Tromas was named pri eipnl. See. Wilcox. Page 10h. him. Nothin came at the second i cidenl. Three years ago l'liunrns appar- ently- erijm'ed that kind ol support, and he defeated Collier [or From Page to Today. armed with Alabama Educa- tion Associatlon attorneys. he has tiled suit to regain the job. which was stripped away in June. Thomas' tall lrom grace seems to typin the politics that permeate the Wilcox County School System. That situation was noted in the stale Department at Education's June progress report on the system The department's team cited on- due influence by sortie board mem- bers "on the selection at personnel to be employed. alten ignoring the rec- ommendations oi the superinten- dentI telling the superintendent who to recommend and then talking ac- lion." "This procedure goes against all acceptable educational standards for the em ploytuent of personnel and gives the appearance of political cronyism.? the report said. Brooks Hotleman, a retired hlont- gomery investment banker and staunch supporter at public educa? tion, said the realities of the that! dis- pute over Thomas' hiring cost Dr. Tumblin her job as superintendent. "Dr. Tumblin hall a loom Harvard. She worked hard. and I tried to help her." Hollernan said. "Oh. she arerdid some things. like hiring too many teachers. She hired 32 teachers above what the slate re- quired to try.- and get the educational process going." overltiring is salt! to bare cost $500,000 and is cited by Some as one at the root causes at the sys- tem's economic problems today. The System may be as much as $2 mil- lion in debt. But liotleman said Dr. Tumblin's biggest problem was "she made Enemies." "Shc suspended Collier from his lab at Pine Hill because he admitted changing his daughter's grades so she could he uatediclorran They [the school board] put him back in." llollemansaid Dr. Tumblin dec ined to tail. about her experiences with the t't'itcns County system. However, her attor- ney, Rich Williams ol Montgomery. said the Thomas incident was essen- tially what brought about her donn- tall. William Pompey. a lormcr school board member and attorney [or the board. said the grade-changing accusation against tTollier is lalse. Pompey said Collier changed the grading system. affecting all grades across the hoard, rather than just the grade at his daughter an- I --. The state Department of Educa- tion's report last June on WIICOI. County schools cited a "general dEa teriomuon of many facets ot the ed- ucatonal process' in the system and said It was caused "mainly by the laclr ol leads-{ship on the part at the administration. Among the shortcomings noted by the report: I No scheduled maintenance program for burlomgs and ulnar la- citaties. data srs- tern. resulting in inaccurate and on- ttmely reports to federal age-noes and the state Department of Edu- cation. I No regular monitoring or tea- ching programs. In serious shonage at test- boohs at -lhe beginning or the school year. u- . dotcnu'luose'f . I Some teacher unrls not tie-'13 untrl late Septembe' or can, October llnadeouale inspection pro- gram for school buses. I Ernsloyrneot ol some ranchers state Pompey also said the system's li- nancial problems have been any gerated. lie said Collier Inherited in- debtedness amounting to about $1 million and has reduced it In essence. Since his removal as superinten- dent, Collier has declined to discuss the school situation with news me- dia. Thomas said he does not unders- tand why he is no longer in lax-or with the school board. but he blames tlollernan. who remains a close friend of Dr. Tuinblin and also op- posed the legislator": appointmenl at the high school "But she was going pretty good until James Thomas. a vocational agriculture teacher who had no perience or training to be a princi- pal. declared he wanted to be princi- pal ol the now 57.5 million comprehensive high school, which is as line as aml high school in the country," ltotteman said, said Dr. Tumblin ap- posed Thomas primarily because his duties as a legislator 1l-rould cause him to be absent lrom school too of- ten Although Thomas had a contract that granted him up to 55 days per year at legislative service lea-re. he maintains that no school business went unattended the said he had as? sistants to [ill in during his absences. "l'rr'l not lot a school teacher be- ing a member of the Legislature. period." Hollernan said ?The princi- pal ol' 3 big high school needs to be there l2 hours a day. sis days a u-eclt. lte needs to be in charge lrorn topto bottom" ?The board can?t hire a principal without the superintendents recom- mendation. though. and got tired because she wouldn't rec ommend Thomas as principal." Hot- leman said. Dr. Tumblin was terminated ir. the spring at td?ll. and Thomas sub- sequently uas hired on the recom mendaIion at an interim superintcn dent. Dr. Tumblin later sued the board in tederat court for 53:30 WEI irt dirt-J ages. Altar several days at testi- mony in 1990. the case was settled tor an undisclosed amount 1-'-'hile the poli'lcal in?ghting goes on. ,the system continues to stiller lrorri Financial problems and pcor achievement lest Scar es. Per-student spending by the tern compares lat-oral. ith that many school districts in .tiahama - $3.395 a year. compared tr. a state average ol 5335?. But its local rev? noes at Elli? per student fall below the statenrde average of tilt Tongue described the otr-rall li nancial situation as "chaos." saying slateofticials could not a bottom line balance [or funds aralt- able Them was slight improvement In Slanlord Achievement Test scores last spring. but the system remains among the worst in the state This grear's testing saw ?-'ilcor eighth-grade students ahead at those in neighboring Lou'nrles County For Ville-re.- was among tllt' IO lowest ll?. state. I GENERAL HIGHWAY MAP WILCOX COUNTY ALABAMA Prepared by STATE OF ALABAIVIA DEPT. BUREAU 0 STATE PLANNING U.S. DEPARMNT OF TRANSPORTATION FEDERAL HIGHWAY ADMINISTRATION 1981 I Vr'moia ?hqsi?xmg A Aespk?ch IQ Depart . 1. HEALTH CARE FACILITIES meat Resource: Sisters at Vredeburgh Clinic APPENDIX daft/:06 73 ?/fawjoj 66 [Jij APPENDIKI 'WILcox COUNTY COMMUNITY NEEDS ASSESSMENT Household Questionnaire I. INFORMATION ON THE INTERVIEW mo day yr 1. Date of Interview 2. Interviewer's Name II. HOUSEHOLD IDENTIFICATION 3. Census tract 1. Alberta 2. Camden town 3. Coy-Fatama Neighborhood Street Name . City . Zip Code ?mmh INFORMATION ON THE HOUSEHOLD A. Type. size, and quality of housing 3. Type of Housing 1. wood 4. mobile home 2. brick 5. other 4. Pine AppleIOak Hill 5. Pine Hill/Yellow Bluff 6. Camden District 3. masonry 9. Number of Rooms Number of Bedrooms 10. Electricity? 1. YES 11. Air Conditioning? 1. YES 12. Heating? 1. YES Describe 13. Telephone? 1. YES 14. Refrigeration? 1. YES 15. Cooking facilities 1. stove/oven 2. other 16. Water Source in House? 1. YES 17. Hot water HeaterMembers of Household 19. Number currently residing in houseHill I List members of household below: relation? sex race date of education* occupation** ship to birth Interviewee Moer 1. Interviewee 19. What is the highest grade you have completed? (number of years) 12=high school graduate 16-co11ege graduate include preschool=PS; Head Startz?s; Kindergarten=K Do you work?; What is your job? IV. INFORMATION ON BREASTFEEDING 20. No. of children under one year of age in the household? If 0, go to #23. 21. Were any of these children breastfed or are you breastfeeding any now? 1. YES 2. NO If YES, how many? 22. At what age is breastfeeding stopped? (months) 68 23. Why was breastfeeding stopped or not started? Indicate all that apply. 1. not enough milk mother was ill infant too old infant could not latch on work outside the home uncomfortablefpainful did not want to be tied down other Chamois-.th 24. If infant fermula is used, is it 1. liquid 2. powder 3 . 25. At what age is water first given to infant (months)? 26. At what age is solid food first given to infant 27. What was the first food you gave your baby? V. ATTITUDES PRACTICES OF MOTHER TOWARD CHILDHOOD ILLNESS 28. No. of children under 10 years in household 29. Have any of your children under 10 been sick in the last month? 1. YES 2. NO If YES, list age and illness below. AQE ILLNESS 4. 30. Are any of your children taking vitamins or iron supplements? 1. YES 2. N0 31. Have any of the children in the household who are under 10 years had diarrhea in the last month? 1. YES 2. NO If YES, complete the following items for each child. If No, go to #33. 59 DIARRHEA CHILD 32a. 32b. 32c. 32d. 32e. 32f. 329. 32h. 321. Age of the child at time of illness (yrs/mos) Type of diarrhea 1. soft 4. watery 2. bloody 5. greasy 3. don't know Duration of diarrhea (days) No. of bowel Place of treatment 1. home 2. health center 3. other 4. none received (go to 32g) Treatment received 1. home remedy (specify) 2. Pedialite or equivalent 3. medicine (specify) 4. other Reason for not treating 1. lack of medicine 2. not serious enough HI 3. lack of money 4. no transportation 5. other Do you know the cause of the diarrhea? 1. YES (specify) 2. NO If YES, do you know what might be done to keep your child from getting diarrhea? 1. YES (specify) 2. NO 33. Have any of your children under 10 had worms in the last 6 months? WORME CHILD 34a. Age of child at time of illness (yrs/mos) 34h. What kind of "worms" did your child have? 1. roundworm 4. hookworm 2. tapeworm 5. pinworm 3. don't know 6. other 34c. Place of treatment 1. home 2. health center 3. other 4. none (go to 34e) 34d. Treatment received (go to 34f) 1. home remedy (specify) 2. medicine (specify) 3. other 34c. Reason for not treating 1. lack of medicine 3. lack of money 2. not serious enough 4. no transportation 5. other 34f. Do you know how your child got worms? 1. YES (specify) 2. N0 349. If YES, do yOu know how to keep your child from getting worms? 1. YES (specify) 2. NO 70 VI. 35. 36. 37. 33. VII. 39. 40. 41. 42. SOURCE OF MEDICAL CARE Where do you usually take your children for health care? 1. private physician (specify) 2. hospital emergency room (specify) 3. health department 4. community health clinic (specify) 5. don't have a regular source of care 6. other COMMENTS Where do you get medicine for your children? 1. pharmacy/drugstore (specify) 2. clinic or doctor (Specify) 3. other How do you pay for health care for your children? 1. Medicaid 3. self pay 2. private health insurance 4. VA benefits 5. other Have any of your children used any of these services in the last 6 months? (Circle all that apply.) 1. Summer Feeding Program for Children 2. Head Start 3. Health Department 4. Rural Clinic Physician 5. Day Care 6. After~schoo1 tutoring program (REEP, Kellogg) 7. Hospital TRANSPORTATION What is your main form of transportation? 1. own car 2. public transportation (specify) 3. walk 4. friend's or family member's car for free 5. friend's or family member's car for money If you must pay, what does a round trip to the doctor cost? Do you ever use public transpOrtation (WAHS van or buses)? 1. YES 2. NO If YES. Specify. If NO, why not? FAMILY INCOME What are your sources of income (for the household}? 1. Work 1. YES 2. NO 2. Unemployment Benefits Food Stamps Social Security 1. YES 2. N0 8. Other 1. YES 2. N0 71 43. Do you own your own house? 1.-Yes, fully paid 2. Yes, making payments 3. No, renting 4. No, living with family/friends IX. DOMESTIC ANIMALS 44. Do you keep domestic animalspoultry 1. YES 2. N0 e. other 45. Do animals come into the houseanimals come into the yard? 1. YES 2. NO comments: 47. Do you have a problem with the following pests? 1. Mice/Rats 1. YES 2. NO 2. Roaches 1. YES 2. N0 3. Flies 1. YES 2. NO 4. other 1. YES 2. NO X. INFORMATION ON WATER USE 43. where did the household get its water yesterday? water in house water water water with pump well without pump city city . well well ,open . other with outside tap (stand with inside tap pipe} If water source inside house, go to #52. 49. Distance from house to water supply (feet) 50. 51. How many times did you (7 days)? 52. Do you drink this water? 1. Time from house to water supply (minutes) YES make this trip in the last 2. NO If N0, where do you get your drinking water? 53. Where do you bathe? 1. showerftub (inside house) 2. other 72 HH week XI. WASTE DISPOSAL 54. Type of excreta disposal 54a. Where do you go to the bathroom? SELF REPORT OBSERVE, IF POSSIBLE number working odors cleanliness distance from house none had good bad (feet) a. indoor _toilet b. latrine c. chamber pot d. other 54b. Where does the water from the toilet go? e. septic tank f. sewerage system g. piped into yard h. other OBSERVATIONS, IF POSSIBLE: toilet paper? 1. YES 2. NO soap? 1. YES 2. NO towels? 1. YES 2. N0 Comments: 55. Solid Waste Disposal 1. regular pick up 4. burn 2. pit 5. landfill 3. dumpster 6. compost T. other XII. ATTITUDES TOWARD BUILDING LATRINE SEPTIC TANK If household has latrine or septic tank (circle one): If not, go to #60. 56. Who built your latrine/septic tank? 1. building contractor 4. friends/family paid 2. friends/family unpaid 5. don't know 3. already there 6. other 57. What made you decide to build your latrine/septic tank? 1. health reasons 2. told by health authorities 3. afraid of being fined 4. other 73 58. Do you think your toilet facilities are a problem? 1. YES 2. NO If YES, why? IF NO LATRINE OR SEPTIC TANK, ANSWER #59?62. 59. Would it be difficult for you to put in a latrine or septic tankYES, why would it be difficult to put in a latrine or septic tank? 1. cost of construction materials 2. cost of labor 3. lack of information on how to build one 4. other 61. If someone were available to help you put in a low?cost facility, would you be interested in building a: 1. latrine 2. septic tank 3. both 4. neither (go to #63} 62. Would you be willing to contribute any of the following towards an improved toilet facility (latrine or septic tank): 1. labor 1. YES 2. NO 2. construction materials 1. YES 2. HO 3. money 1. YES 2. N0 4. nothing 1. YES 2. ND 5. other 63. What is your family's biggest need right now? OBSERVATIONS: 64. Cleanliness of interior 1 2 3 4 5 Good Bad Describe 65. Yard Cleanliness 1 2 3 4 5 Good Bad Describe 66. Housing in need of repair? 1. YES 2. N0 Describe 74 APPENDIX HEALTH CARE PROVIDER SURVEY Date of Interview Interviewer Place NAME: JOB ADDRESS: RACE: NW SEX: APPROX. AGE HOW LONG HAVE YOU BEEN WORKING IN WILCOX _years Comments: WHAT COMMUNITIES DOES YOUR PRACTICE WHICH OF THESE MCH SERVICES DO YOU pediatric care? immunizations? prenatal care? I family planning? If No, where do you refer your clients for these services? WHAT PERCENTAGE OF YOUR PRACTICE IS UNDER WHAT ARE THE MOST COMMON CHILDHOOD ILLNESSES THAT YOU SEE IN CHILDREN UNDER 5 IN YOUR WHAT IS THE PREVALENCE OF THESE CONDITIONS IN YOUR diarrhea 1 2 3 4 5 very hi high low very low intestinal parasites (acute resp. infection) scabies 1 2 3 4 5 conjunctivitis 1 2 3 4 5 lead poisoning 1 2 3 4 5 75 WHAT IS CONSIDERED TO BE DIARRHEA FROM A CLINICAL (case definition) WHAT ARE THE MAJOR CAUSES OF ARE THE MAJOR INTESTINAL DO YOU DO TESTS TO CONFIRM YOUR Comments HOW DO YOU TREAT HOW DO YOU TREAT INTESTINAL DO YOU RECOMMEND HOME TREATMENT FOR If so, what do you recommend? WHEN IS DIARRHEA SERIOUS ENOUGH FOR TREATMENT IN A HEALTH HOW OFTEN ARE CHILDREN HOSPITALIZED FOR DEHYDRATION ASSOCIATED WITH 1 2 3 4 5 very often often seldom never HAVE THERE BEEN ANY DEATHS ASSOCIATED WITH DIARRHEA IN THE LAST 5 IS THERE A PARTICULAR AGE GROUP THAT IS MOST SUSCEPTIBLE TO DIARRHEA INTESTINAL COmments: IS THERE SEASONAL VARIATION IN THE INCIDENCE OF THESE Comments: ARE THESE CONDITIONS MORE PREVALENT IN SOME If so, which ones? WHAT DO YOU THINK ARE THE BIGGEST PROBLEMS FACING WILCOX 76 DO YOU THINK THERE ARE ANY BARRIERS TO THOSE SEEKING HEALTH CARE IN-WILCOX If so, what are they? SERVICE INFORMATION RESPONDENT (if different): WHAT DAYS AND HOURS IS YOUR PRACTICE ARE THERE CERTAIN TIMES FOR PARTICULAR Specify: ARE ALL APPOINTMENTS DO YOU ACCEPT What percentage of visits are walk-ins? NUMBER OF STAFF WORKING IN List by job title: WHAT CLINICAL SERVICES DO NON-M.D. PERSONNEL HOW MANY PATIENTS DID YOU SERVE IN 1991? HOW MANY TOTAL VISITS DID YOU HAVE IN 1991? HOW MANY PATIENTS DO YOU SEE ON AVERAGE PER WHAT PERCENTAGE OF YOUR VISITS ARE WHAT PERCENTAGE OF YOUR CLIENTS ARE WHAT IS THE AVERAGE WAITING TIME FROM REGISTRATION TO BEING SEEN BY MEDICAL IS OUR PATIENT LOAD: 1 2 3 4 5 too heavy right too light DO YOU ACCEPT PERCENT OF DO YOU ACCEPT UNINSURED PERCENT OF DO YOU HAVE A SLIDING SCALE OF CAN A PATIENT PAY ON ARE THERE OTHER MEANS OF If specify: WHERE DO YOUR PATIENTS GET THERE OBSERVATIONS WAITING ROOM Are there health promotion materials? Describe Is the waiting room pleasant? 1 2 3 4 5 good fair bad crowded? 1 2 3 4 5 temperaturethere something to entertain children? COMMENTS: 7B PREVALENCE 0F INTESTINAL HELMINTHS WILcox COUNTY, ALABAMA Participating Alberta Maureen Nichols 573?2493 Pine Apple Dr. Cook 746-2197 Vredenburgh Pat Hauser 337-4781 Yellow Bluff Dr. Moskovich 963-4201 UAB of Publig Health lLaboratoryl (Call Dr. Stephensen if you have any questions.) Charles Stephensen 934-1732 Pauline Jolly 934?1732 Walter Mason 934?1732 School of Public Health 106 Tidwell Hall 720 S. 20th Street University of Alabama at Birmingham Birmingham Alabama 35294 Osman Banaga 293-4468 (Alabama State University) Questions abggt treatment: Call Dr. Craig Wilson, Division of Geographic Medicine, UAB School of Medicine, Children's Hospital; 934-1539. Dr. Wilson is a pediatrician with extensive experience in medical parasitology. goal 9: Study: Determine the prevalence of infection with intestinal nematodes in children under 10 years old attending Alberta, Yellow Bluff, Vredenburgh, and Pine Apple Clinics. Who will be asked to participate: All children under 10 years of age who come to the clinics, regardless of the reason for the visit. Children will be tested only once. Starting date for recruiting subjects; October 26, 1992. Number of sub' 212 is the target, or 53 per clinic. consent prggedure: The nurse, nurse practitioner, or physician seeing a patient will need to elicit written, informed consent from the parent or legal guardian of the child. The key elements of asking for consent are explaining the purpose of the study in simple language and indicating that participation is entirely voluntary and declining to participate will not affect their medical care. The study must be explained to the child as well and, if the child is 7 years old or older, he or she needs to sign the consent form as well. Two consent forms must be signed. Please give one to the parent and keep one in the notebook. 79 Wha me with th ati nt: 1. stoo1_cup with 2 labels: 2. Wh he imen ome 1 Label 1: Patient name or clinic ID code (remove this label before sending specimen to UAB) Label 2: age sex zip code date of clinic visit tongue depressor beck the inic: . Scoop no more than 5 9 (about 5 ml) of stool into the 50 m1 plastic screw-cap tube containing 20 ml of 10% neutral buffered formalin and mix well. The final volume will be about 25 m1. If you have sufficient stool, prepare one additional tube for each subject. 2.Transfer the label with the age, sex, zip code, and date of clinic visit to the screw-cap tube. (Screw the lid on 3.Assign the specimen a study number in chronological order) to the specimen and write this number both on the specimen tube and on your record sheet. 4.Store the specimen at room temperature until it is picked up or you send it to the lab. Clinic Stu mber Alberta 1001 1999 Pine Apple 2001 - 2999 Vredenburgh 3001 3999 Yellow Bluff 4001 4999 simple flotation method will be used to concentrate any helminth ova. then be examined by direct examination. Helminth ova will This method that we will use is designed principally to identify Ascaris (roundworm) and hookworm ova. We plan to give you result (positive or negative for Ascaris or hookworm} within 2 weeks of receipt of the specimen. 80 APPENDIX Wilcox County Results of Household Survey 31 VRED. X-MAS COUNTY 1. Number of households surveyed 30 129 159 2. Total number of childxen <10 70 268 338 CHRISTMAS SAMPLE 3. Number of householdsiu'act Acuml Total Weighted against census Sampled hi] :1 <10 Samgle ALBERTA 34 3 10 40 CAMDEN 48 412 49 COY-FATAMA 25 134 17 PINE APPLEJOAK HILL 23 182 23 PINE HILIJY. BLUFF 87 620 36 CAMDEN TOWN 184 Total 263 2092 268 PHYSICAL CHARACTERISTICS OF HOUSEHOLD VRED. -MAS mm 4. Frequency by type of housing WOODEN 20 53 73 26 27 MASONRY 0 MOBILE HOME 9 45 54 OTHER 0 4 4 5. Freq. with telephone 10 83 93 Freq. without telephone 20 46 66 6. 7. 10. ll. 12. 13. Frequew with air oonditioni 11g Frequency withom air cond. Frequency by type of heating use a combination of methods) GAS ELECTRIC WOOD CENTRAL KEROSENE SPACE HEATER HEAT PUMP OVEN OTHER Frequency water in house Freq. withom water in house Frequency with hot water Freq. without hot water Fretluemrj)r with refrigerator Freq. without refrigerator Frequency with washer Freq. without washer Frequency with dryer Freq. without dryer Number of residentarhousehold Number of roomsfhousehold NUmber of hedroomsfhousohoid Number of VRED(411%) 1 29 6.16 5.53 2.92 82 X-11111 5.42 6.79 2.94 1.84 9.01m 115 5.56 6.55 2.93 1.90 CHARACTERISTICS or RESIDENTS 14. 15. I6. 17. 173. 1711. 18. 19. 20. Frequency by race WHITE Number of eh?dren<10fhousehold Frequency by relationship of caretaker MOTHER GRANDMOTHER AUNT GR. GRANDMOT. SISTER Frequency by age of caretaker <2 18 years 18-21 years 22-29 years 30-39 years 40-49 years 50-59 years >60 years Average age of caretaker Range of ages of caretakers Average education of caretaker Frequency of highest grade completed by earelaker by level of education 12 GRADE 12 GRADE 12 GRADE Average number of adults>181f household VRED. 30(30 (100%) 0130 2.years 22-61 years 1001 grade 20 10 2.5 83 103(129 211129 2.07r 101 19 1 1116-78 11111 46 59 24 2.24 331059 211159 2.16?78 11111 66 69 24 2.28 VRED. 21. Average number of adult males! .93 household (16-64 years) 21a. Frequency of adult males! household 0 9 1 15 >1 6 22. Number adults: 12 grade! 30 household 23. Frequency of households with 31 MEMBER 16 NO ONE 14 outside of home) BREAS DIN 24. Frequency of breastfeeding, 011 of children <1 year MORBIDITY 25. Frequency of children with 13 diarrhea reported within last month (Average age of child with diarrhea=4.27 years) 26. Fresquencg,r of children with worms reported within last 6 months KMES .61'42%) 631 30 5 (However, 32 children had previous history of worms and 4 mothers treat regularly) HEALTH CARE 27. Frequency of use of health care by provider PMD 9 EMERGENCY ROOM 1 RURAL HEALTH CENTER 21 NO REGULAR SOURCE 7001492.) 3 28. Frequency where medicine is obtained by source (may be obtained from 1 source) PHARMACYIDRUGSTORE CLINICIDOCTOR OTHER 29. Frequenq' of how health care ispaidfor?mayuse> 1 source) MEDICAID PRIVATE INSURANCE SELF PAY VA BENEFITS 30. Frequency of use of available senrices {in last 6 months) SUMMER FEEDING PROGRAM HEALTH DEPARTMENT RURAL HOSPITAL SP RTATION 31. Frequency by main form of transportation OWN CAR PUBLIC TRANSPORTATION WALK FREE FRIENDIFAMJIX PAY 32. Of ?mse who pay, average amount paid for a round trip to the doctor RAN GE 33. Frequency of use of public transportation (W. Alabama Health Services Van) 34. Why public transportation not used; by frequency of most common answer ACCESS TO A CAR NOT AWARE 0F THOUGHT FOR ELDERLY VRED. 26 7 3 (111$8.80 ($150-$211) 10/113 53 9 13 17 COUNTY 147 39.9] 11/143 69 19 19 22 SOURCE OF INCOME 35. Frequency of source of income by type WORK UNEMPLOYMENT ADC FOOD STAMPS W1C SSI (Disability) SOCIAL SECURITY CHILD SUPPORT 36. Frequency,r of house ownership YES NO PETS PESJE 37. Frequency of pet ownership DOGS CATS PIGS POULTRY 38. Frequency of animals in house YES NO 39. Frequency animals in yard YES NO 40. Frequency of pests in house MICEIRATS ROACHES FLIES ANTS WIREDI X-41WATER Frequency of source of water by type CITY WATER IN HOUSE 24 76 100 CITY WATERJSTANDPIPE 6 6 12 WELL TAP 0 38 38 WELL WATERJPUMP 0 2 2 OPEN PUMP 0 1 EWATER 0 6 6 1 (NO WATER 1N HOUSE) 6 15 21 Frequency of type of toilet WDOOR-STANDARD 25 114 139 POUR FLUSH 1 1 3 WOODS 0 1 1 NEIGHBOR 3 1 4 CHAMBER PDT 0 2 2 LATRJNE. 1 4 5 (NO INDOOR STD. TOILET) 5 15 20 Frequency of type of sewage disposal SEPTIC 57 58 SEWER 19 25 44 PIPED INTO YARD 5 20 25 OTHER (ex. 0125513001) 5 27 32 (OTHER THAN 10 47 57 01' those who have septic systems, frequency that are (determination not made at all households) WORKING 36 36 NOT WORKING 1 (100%) 11 12 Frequency of working showerfbalh in house 21 115 136 SOLID WASTE DISPOSAL Frequency of solid waste disposal by type REGULAR PICK UP 29 29 58 DUMPSTER 0 38 88 BURN 3 27 30 EX VRED. ISTING LATRINES AND SEPTIC TANKS a 47. 48. 49. Frequency by who built the facility PROFESSIONAL CONTRACTOR FRIENDSIFMY WPAD) I ALREADY THERE 2 FRIENDSIFMY PAID 0 Frequency by "whyr the facility was built" HEALTH REASONS (100%) TOLD BY AUTHORITIES 0 OTHER 0 IrDo you think that your toilet facilities are a problemBUILDING A SEPTIC TANK OR LATRINE Responses ?'om households that have nothing or a septic system that is not working. 50. 51. 52. ?Would it be dif?cult for you to put in a latrine or septic tank?? YES 8 NO 1 "Why would it be di?icult?" COST OF 4 COST OF LABOR 4 NO MORMATION SOIL PERCOLATE 3 RENTWG 1 "If someone were available to help you put in a low-cost facility, would you be interested in building a: LATRINE 2 SEPTIC TANK 5 BOTH 0 NEITHER 53. ?What would you be willing to contribute?" LABOR 4 CONSTRUCTION MATERIALS 2 MONEY NOTHING 54. Family's biggest need right now (most oonunon answers) HOUSE REPAIRED 6 NEW HOUSE 2 MORE ROOM 3 (1 MONEY 0 BATHROOM 4 (including water, toilet, septic, etc.) HEAT 5 CLOTHES 2 FOOD CAR 0 JOB NOTHING 4 OBSERVATIONS 55. Cleanliness of house (5-point scale) basal on overall condition of house, including need of repairs - l=good 5=poor 2 56. Cleanliness of yard based on presence of rubbish, standing sewagelwater, animals, etc. 1=good 5=poor COUNTY APPENDIX Results of Household Survey for CHILDREN WITH DIARRHEA Magi; mm; HOUSEHOLD CHARACTERISTICS 1. Tract ALBERTA 1 CAMDEN 3 COY-FATAMA 2 PINE HILL 4 CAMDEN TOWN 8 (VREDENBURGH) 13 (100%) 2. City ON 1 1 CAMDEN 11 COY 2 PINE HILL 3 (VREDENBURGH) 13 {100%} 3. Zip code 36435 (Coy) 2 36481 (Vrodaenburgh) 13 (100%) 36720 (Arlington) 1 36722 (Boykin) 1 36726 (Camden) 11 36769 (Pine Hill) 3 4. Telephone in household YES 6.146%) 14 N0 7 4 5. Water inside of house YES 13 (100%) NO 0 1 6. Hot water in household YES 11 15 NO 2 3 90 Washing machine owned by household YES NO 8. Average number of residents in household 9. Race of children NON WHITE WHITE 10. Average number of children <10 in household CARE ARACTERISTICS 11. Average age of caretaker lla. Range of ages of caretaker 12. Relationship of caretaker GRANDMOTHER 13. Average education of caretaker 13a. Education of caretaker <12th GRADE =12th GRADE >121h GRADE ADULTS IN HOUSEHOLD 14. Frequencjr of males [16-64) in household 0 MALES 1 MALE >1 MALE 15. Frequency of households with at least one member working mm ID 3 6.15 13 (100%) 0 2.8 34.5 years 26-47 years to 3 11th grade 2.1 36.4 yeaxs 23-61 years 15 3 3 5 3 (441%) to 56%) 0 11 16. Frequency of adults in household with >_121h grade education CHILDHOOD MORBIDITY 17. 18. 19. 20. 21. 22. 23. Average age at illness Type of Diarrhea 12 months 12-23 months 24-35 months 36-47 months 43-59 months 60-71 months 72-33 months 34-95 months 96-107 months 108-119 months SOFT BLOODY GREASY KNOW Average duration of diarrhea Duration of diarrhea <7days 27%? Average number of bowel movements per day Bowel movements per day Many 4-6Iday Howey Place of treatment HOME HEALTH CENTER OTHER NONE RECEIVED Vreden 3.7days 12 1( ?uidity Chrim 5.3 days 13 5 5 . Slday 24. 24a. 24b. 24c. 25. 253. 26. 26a VManurgh Treatment received (Reapondents could give more than one answer) HOLE REMEDY 3 PEDIALITE (or equivalent) 2 MEDICINE ll OTHER 5 Home Remedies include: juice, soup, crackers, ?our, and water. Types of Medicine given: PEPTO BISMAL 9 2 DONAGEL 2 ANTIBIOTICS MYLANTA 0 Other treatments given include: fluids, I'regular' food, no water, soda, crackers, bananas, warm milk, and black draught symp. Reasons for not treating LACK OF MEDICINE 0 NOT SERIOUS ENOUGH (100%) LACK OF MONEY NO TRANSPORTATION 0 OTHER 0 OTHER reasons for not treating include: called the doctor and late at night. Knew the cause of the diarrhea YES 3 NO 9 what was the cause VIRUS 3 JUICEISWEETS ANTIBIOTICS 0 SPICY FOOD 0 TEETHING 26b. EYES, do you know what he done to keep child from getting diarrhea YES NO 2'7. Child has had worms in last 6 months YES NO HEALTH CARE 28. How is health can: for the child paid for? (may be more than 1 source) MEDICAID HEALTH INSURANCE SELF PAY FANIILY 29. Sources of 11100111: for the household WORK ADC FOOD STAMPS 30. Do you own your home? YES NO 3 1. Do you keep any domestic animals? DOGS CATS PIGS POULTRY 31a. Do animals come in the house? YES NO 3 lb. Do animals come in the yardChrimgg 0 12 (100%) 18 (100(100%) 0 Vmenburgh mamas PESTS 32. Have a problem with the following MCEJRATS 10 4 ROACI-IES 12 9 WATER a: SANITATION 33. Where household got its water yesterday CITY WATER IN HOUSE 13 (100%) 14 WELL WATER {inside tap) 0 3 1 34. Type disposal INDOOR TOILET 13 (100%) LATRINE 35. Toilet working YES 12 15 NO 1 3 36. Typeofsewagedisposal SEPTIC TANK SEWERAGE SYSTEM 7 6 PIPED INTO YARD 1 OTHER 1 3 363. OTHER forms of sewage diSposal include: cesspool, Ian-inc. bucket, and dOn't know 37. Sewage disposal working YES your toilet facility a problemSOLID WASTE DISPOSAL 39. Solid wane disposal REGULAR PICKUP DUMPSTER BURN PILE BEHIND HOUSE PERCEIVED NEEDS 40. Family's biggest need right now MORE ROOM MONEY HOUSING REPAIRS CHEAP HEAT TOILET NONE 41. Cleanliness of interior (5 point scale} GOOD 1 FAIR Lab-uh.) BAD 42. Cleanliness of yard (5 point scale) GOOD I FAIR Lilli-WM BAD 13 (100Christmas APPENDIX Chart Audit Data- Alberta Clinic Patients under 10 seen 7/91-6f92 Diagnosis=Enteric Pathogen Original Audit 10/92, Follow-Up 2/93 DQ. V: date of 1est Diagnosis: RS =reeta! smear: =posin've for W=ronnd worms Pr. assigned by researchers Sex: =ma1'e. a? female Age: in years unless speci?es months his: 2 numbers ofzr'p code FW=?at worms We drug used Si A2: 3.12 D-O-1251191 RS RW PIPERAZINE 2 4 20 4.9392 R3 RW, FW PIPERAZINE 3 4 ms 28 6f19f92 RS RW PIPERAZINE MINI DIARRHEA 4 5 11105 28 6f4i92 RS RW PM 5 5' 28 4f6f92 R3 RW PIPERAZINE 6 3 33 5114/92 RS RW PIPERAZINE 7 4 69 U992 R5 RW PIPERAZINE 3 8 20 4:97.92 R5 RW PIPERAZINE 9 4 73 INI92 R5 RW PIPERAZINE 10 8 20 4f6i92 RS RW PTPERAZINE 11 9 20 3120.79] R5 FW ANTIMINTH 12 6 20 SIIWQI RS RW PIPERAZENE 2113192 R8 RW PIPERAZINE 13 2 20 234/92 R3 RW PIPERAZINE 3/51?92 R5 RW PIPERAZINE 6f 181'92 R5 RW 98 IE: '11 '11 3?11 3 20 21432 3151'92 4f9f92 12f2 8192 ?73 11?64'91 20 811391 20 2f2'h'92 3/26!? 28 3!12f92 20 3112192 20 l!9!92 28 Sil U92 23 1127192 9/24/92 23 10.!r 28 20 1 1:22:91 20 3124192 20 618192 $1232 1012 1/92 112 [{93 20 Ill ND CHART 23 [?30192 23 3I2 3:92 20 112332 28 U24i92 20 Ill 3N2 2G 119f92 6(24f92 RS RW MOM TI-UNKS RS RW G?ma thinks G'ma test G'ma thinks PIPERAZINE PIPERAZINE PIPERAZWE VERMOX PEPERAZINE PIPERAZINE PIPERAZINE PIPERAZINE PEPERAZINE PIPERAZWE PIPERAZINE PIPERAZINE PEPERAZINE VERMOX PIPERAZINE PIPERAZJNE PIPERAZINE PIPERAZWE VERMOX Stool cup given, not manned Momthinks 99 PIPERAZINE PIPERAZINE PIPERAZINE VERMOX PIPERAZINE PIPERAZINE PIPERAZINE 323:: ?"9333? '11 29 211-1192 as gross amt. RW 67 1013191 R5 WY RW 312192 R5 11911 N0 CHART 211 4122192 R5 grass 1 RW 2111 12113191 RS 11w 33 3111192 R5 MANY LG. RW 511192 RS RW 23 10116191 R3 RW 113192 R5 RW 1016192 MOM THINKS 23 3123192 R5 RW '13 3116191 R5 RW 28 2121192 RS RW 28 1116191 R5 MANY RW NO CHART 20 214192 RS RW 20 1113191 618/92 R5 11w 20 1013191 R5 FW 4113192 R5 RW 20 5114192 RS RW 20 4113192 RS FW 20 3120192 R8 RW 4115192 RS RW 20 1012819] Passed FW R5 FW 2127192 R5 RW 5113192 RS 11911 20 4116191 R3 MANY RW 2121192 R5 1191 4115192 RS RW 20 12113191 100 PIPERAZINE PIPERAZWE PEPERAZINE PIPERAZINE PIPERAZINE PIPERAZINE PIPERAZINE PIPERAZINE PIPERAZINE RX FOR PWORMS PIPERAZINE PIPERAZINE PIPERAZWE PIPERAZINE PIPERAZINE PIPERAZJNE PIPERAZINE PEPERAZINE PIPERAZINE PIPERAZINE '11 '11 "11 8mm; 20 3/5/92 RS RW 20 1/1592 RS RW 20 9! 1819] RS FW 4f13f92 RS MANY RW 23 133192 R5 RW 20 311632 RS RW 20 615192 RS RW 20 3123.92 RS RW DIARRHEA 20 Zfl'h'92 R5 RW 35192 VOMJDIARRHEA RS MANY RW NO CHART 23 7182'91 RS MANY FW 23 RS MANY LG. FW 23 IUIIWQI RS MANY LG. RW 28 U632 R5 MANY LG. RW N0 CHART 28 2! 16:92 RS MANY FW 23 SB U91 R5 MANY RW 23 2111.92 RS RW R3 RW NO CHART 23 10129191 DIARRI-IEAIVOM RS MANY LG RW 23 8I27f91 SIBLING HAS R5 MANY LG. FW N0 CHART 23 IOIIWQI R3 MANY LG. 2119'92 REQUEST 28 35192 DIARRHENGE. 101 PIPERAZDQE PIPERAZINE PIPERAZINE PIPERAZINE PEPERAZINE PIPERAZHNIE PIPERAZINE PIPERWE PIPERAZDQE PIPERAZINE PIPERAZINE PIPERAZWE PEPERAZINE VERMOX PARAPENTOLIN 100 101 '11 23:: 35215 W92 3a'251?92 2f?! 92 919.191 9f30f9 10! 1019] SI 11" 92 7130192 1/6192 2! 12192 5H7f92 6l4f92 9?4f91 4121.192 Zil'?92 4Hf92 4W92 43192 31" 123'92 61'] W92 Zil?i92 6! 15192 10f22l9 1 219192 1.01.192 121991 9il3f9l 6/2192 Eil?f92 71'171'91 2f4f92 R3 RW PIPERAZINE RS MANY RW PIPERAZENE RS MANY RW PIPERAZINE R5 RW PIPERAZINE R5 WY RW PIPERAZINE RS MANY RW ANTIMINTH R5 RW ASCARJS VERMOX R5 RW PIPERAZINE R3 4- RW PIPERAZINE RS RW PIPERAZINE NO TEST PIPERAZINE R3 RW PIPERAZINE R5 RW R5 RW PIPERAZINE R5 RW PIPERAZWE RS RW PIPERAZINE RS RW PIPERAZINE RS RW PIPERAZINE REQUEST PIPERAZME RS RW, PW PIPERAZDIE R3 RW ANTIMINTH RS LG RW, FW R5 FW PIPERAZINE NO TEST VERMOX R3 RW PEPERAZDJE R3 RW PEPERAZWE R5 RW PIPERAZINE R3 RW RS RW PIPERAZINE R5 RW PIPERAZINE RS RW PIPERAZINE R5 KW PIPERAZINE 102 102 103 104 105 106 107 108 109 110 111 112 113 114- 115 116 117 118 119 120 limos 5120192 3116192 3116192 3118192 3120192 4123192 3116192 10110191 214192 614192 6116192 612 3192 6123192 10114191 51131 92 1012191 10114191 112192 9122192 1124192 12115192 9113191 10128191 112192 4124192 614192 11112191 1129192 3119191 10116191 10124191 6124192 NOTEST RED, BLUE, GRAY Rs. MOM BRINGS WORM VOM. 2 WOW Scratching1P1NWORMS RS RW R5 RW DIARRHEA 103 PIPERAZINE PIPERAZINE PIPERAZINE PIPERAZINE PIPERAZDJE PIPERAZINE PIPERAZJNE PIPERAZJNE PIPERAZINE PIPERAZINE PEPERAZINE PIPERAZINE PIPERAZENE PIPERAZINE PEPERAZENE PIPERAZHJE VERMOX PIPERAZINE VERMOX PIPERAZINE PEPERAZINE PIPERAZINE PIPERAZINE PIPERAZINE PIPERAZINE PIPERAZINE PARAPENTOLIMFLUID PIPERAZINE 121 122 123 I24 125 126 127 128 '11 20 6f5f92 23 61'151'92 73 1/982 N0 CHART 20 1050/91 20 1 1319191 6131'92 NO CHART 20 327492 5f4f92 104 PIPERAZHQE PIPERAZWE PIPERAZJNE PIPERAZDJE PIPERAZINE PIPERAZINE PIPERAZINE PIPERAZDQE PEPERAZINE RESULTS 128 CHILDREN IDENTIFIED WITH ENTERIC PATHOGEN (7/91-6f92) IN ORIGINAL AUDIT 10i92 AT THE ALBERTA CLINIC. 8 CHARTS MISSING AT FOLLOW-UP. TESTING: 117 CHILDREN TESTED POSITIVE WITH A RECTAL SMEAR FOR HELMINTHS AT LEAST ONCE DURING THE STUDY PERIOD (791-692). 3] CHILDREN TESTED POSITIVE FOR HELMINTHS MORE THAN ONCE DURING THE STUDY PERIOD. 20 CHILDREN TESTED POSITIVE FOR FLATWORMS. 152 CASES OF WERE TREATED FOLLOWING A POSITIVE RECTAL SMEAR. 14 CASES WERE TREATED WITHOUT A POSITIVE TEST. (based on mother?s wishes, or actual passing or vomiting a worm) DRUQ PIPERAZINE WAS USED TO TREAT THE INFECTIONS 85.5% OF THE TIME (142 out of 166 treatments). Wm WAS. USED 14 TIMES PERMOX WAS USED 9 TIMES DICYCLOMENE WAS USED ONCE 105 CHART AUDIT OF Children in UAB Stool Sample Survey $12 ?2 Prob] Mia 1001 10/281512 5 23 No recent history 1002 101'29/92 7 23 Diarrhea (8.15192) 1003 1080192 2 28 No recent history 1004 1080/92 6 28 R5. F. W. and RW. Rx-Antiminth (2120191) 1005 1112192 8 23 UAB for worms Rx-Piperazine (12/2232) 1006 1122(92 7 28 No recent histmy 1007 1112192 9 23 No recent historyr 1003 11113192 2 20 Cold R5 RW (3111191) Cold, Abd. Pain R5 RW {316192) 1009 11/3192 4 23 Vom. RS. many KW. Rx-Antimt'nth (1127192) Morn wants checked 11.8. RW Rx-Piperazine (4121192) Nasal Con, Scratch Diag.-Pinwonns Rx-Vermox (1012192) V0111. 1 wk, Scratch Rx?a?et wean stud),r (114193) 1010 11113192 3 20 Cold, Abd. Pain RS PW Rx-Amiminth (3!11!91) Cold, loss of appetite R5 RW Rx-Antiminth (4117191) Cold, Abd. Pain R5 RW 106 1011 1012 1013 1014 1015 1016 1017 1018 1019 1020 (UAB 1021 1 114292 1 114.92 11?4/92 1 H432 lli4r'92 1 114.192 1111632 11f16!92 ll.?r 16192 1111711922 107 Rx- Pipemzinc (35/92) No recent historyr R5. many worms Rx-Antiminth (W39) Abd Pain, Nausea, Vom Rx-Piperazine (le 1?92) Abd Pain, Nausea, Von: R5 many RW Rx-Pipcrazinc Missing chart RS my Ascaris Rx-Antimimh (917%) RS my RW Rx- Antiminth (l lfl2f90) Cough, Elev. Temp R5 many RW Rx-Antiminth (3I4I91) Vom, Abd. Pain R5. KW. Rx-Piperazine (1:09:92) Missing Chart Teacher saw worm in stool R5 many worms Rx-Antiminrh (6i15l?89) R5 many RW Rx-Piperazine 16:92) cold, nausea, Vom, diarrhea Rx-Foroo ?uids (21'1/93) Mom thinks has worms R5 FW Rx- Antiminlh (ts/15139) UAB RW (IZIZUQZJ Mom saw lg. white worm Antiminlh No recent history 1022 1023 1024 1025 1026 1027 1028 1029 1030 1031 (UAB 11119192 1 1.1301Ir 92 12111192 132.192 1 2141'92 1218192 12111192 121'] 1192 121141'92 12130392 110 1 11108 Vain. RS RW Rx-Antiminth (6116.191) Elev. temp, shaking RS RW Rx-Pipemzine (1118192) PM. gmnting. Vom. Mom thinks has worms Rx-Piperazine [1016192) Gut worms, G'ma saw Rx-Vennex (1119.192) Diarrhea-KP (no result) Parapentolin Fluids (10/24/91) Elev. Temp. RS my worms Rx- Antiminth (9122/39) Anemia, Fail. to thrive RS many FW R3 many RW RX-Piperazine (8.11931) Congestion R5 RW Rx-Pipemzine (21181112) No recent history Elev. Temp. R3 My PW Rx-Piperazine {9118191) V0111. RS many RW Rx-Piperazine (4113/92) RS my ascaris (5116/91) No recent histon Abd. Cramps R3 Rx?Piperazine (10130191) UAB RW (219193) Vent. R3 my long FW Rx-Piperazine 10122191) 1032 1033 1034 1035 1036 1037 1038 1039 ll!30l92 12130192 12(301'92 1280/92 1.93 1193 1.06/92 219193 911105 109 Vom, Abd Pain Pepte Bismal at home R5 many RW (3/11f91) R3 many RW (12114l90) Abd. Pain, Loss Appetite R5 (1118190) Rectal itching RS Rw (115x39) RS many eggs and RW (1/2090) Cough, Vent, Chest Con. RS RW Rx-Antiminth (1:22:91) Ne recent history Cold, Chest Congestion RS RW Rx-Piperazine (621992) No recent history Elev. temp. RS RW Rx- Piperazine (61852) Grit teeth, Vern, Elev. temp G'ma thinks has wemts (8/1232) Sleeps on knees, scratch G?ma thinks has worms RxNennox (10121512) Cold, G'ma thinks has wenns Steel sample to UAB (1f21l?93) No Rx No recent history RESULTS I Chart review of subjects (1001-1039) ??om the Alberta Clinic that are included in the UAB stool sample survey. 37 CHARTS PULLED 2 CHARTS MISSWG 14 CHILDREN HAD NO HISTORY OF HELMINTHS PRIOR TO UAB STUDY. ll CHILDREN TESTED POSITIVE FOR WITHIN THE LAST YEAR. (1 child tested positive, but there is no documentation to show that she was treated) 11 CHILDREN (30 WERE TREATED FOR HELMINTI-IS WITHIN THE LAST YEAR. (1 child was treated without a rectal smear, because the grandmother saw the worm) 21 CHILDREN HAVE TESTED POSITIVE FOR HELMINTHS IN THE PAST. 4 children tested positive without documentation of treatment) 19 CHILDREN HAVE BEEN TREATED FOR HELMINTHS IN THE PAST. (2 children were treated without a rectal smear, because the caretakers saw the worms.) 12 CHILDREN HAVE OF MULTIPLE (more than one) INFECTIONS. UAB POSITIVES Subject 1005- NO HISTORY or HELMINTH INFECTION Subject 1020? TREATED FOR HELMINTHS IN 1937. Subject #1031- TREATED FOR 10f22f9]. APPENDIX Resource: (16) More than prescriptions .- . 1; Dr. Cook dresses sore on leg of 83- relatives to bring him medicine. year-old Melvin Stallwortn, a shut-in who I Dr. Roseanne Cook, a mm, and her clinic serve 2,500 people in isolated Wilcox County. I Despite public efforts to recruit more doctors like her, few stay long at poor, rural practiCes. I Throughout the nation, there are counties like . Wilcox, where people have no money, no insurance, and little access to - health care. NEWS STAFF SDNGER eoends on Nun struggles against poverty in Wilcox medical practice By Betsy Butgereit News staff writer PINE APPLE Far from the University of Alabama at Birmingham's brick towers. far from the snarled urban traffic. far from the packed fnalls crowded with holiday shoppers is the concrete-block Grace Busse Health Clinic. Here, a doctor doesn?t tote around a fancy black bag or briefcase. She hauls her supplies to house calls in a Sears "Where America Shops" plastic bag. . Here, families return the prescriptions of their recently deceased relatives the clinic can reuse the plastic bottles. Here, patients are likely to leave toting their prescription drugs in a cleaned-up Frosty Acres frozen black-eyed peas hag. And here is Dr. Roseanne Cook, 54, a Roman Catholic nun who went to medical school at age all and has been serving in TWilcolt County's Third lWorld conditions of sickness and poverty for seven years. One of four doctors serving the counly's 14,000 mostly poor people, she jumped from non as biology teacher at Fontbonne College in St. Louis, to non as doctor at the suggestion of some other fellow Sisters of St. Joseph. Her days begin early, end late and often are surprising. For example. as she heads out the Clinic door at mid-morning to make a hovse call, Frank Partin stops her. Gift from a friend A courtly man given to kiosing the hands of women as a greeting, he asks, "Are you leaving now?" She says yes. "Well, I have something for you," he says. She follows him to his beat?up gray pickup truck, where he presents her with a Winn Dixie plastic bag that's lumpy at the bottom. ?Whatcha got there?" she asks, then real- izes it's sweet potatoes that he has dug up for her. "These look like great ones," she tells him and stashes the bag in her car. He's pleased that She's pleased. Dr. Cook met Pal-tin shortly after she was recruited to Pine Apple by Sister Jane Kelly. a nurse practitioner also of the Sisters of St. Joseph. Partin?s wife, Miss Laura, was dying from cancer and Dr. Cook made many house calls before she died. Partin, a logger who qualifies for Medicare in May, can't read or write. she says. ?but he comes around every year with a Christmas card because the writings already on it. and he hands it to you, so you know who it's trom." He loves Dr. Cool-t, he says, because she came to see his wife without even being called. A devout Baptist, he?s got no problems with a nun who goes doctoring. ?Denomination don't spell nothing with me," he says. ?In my mind, it everybody joined the church of Christ that's within," and he taps his chest with his right hand, ?it would he all right. Denominations don't spell Christ." This clinic is 25 miles from Camden and about 30 from and their hospitals. It's the kind of rural setting that the medical community now is gnashing its teeth over how to serve. See Nun, Page Edit I Nun Page 1A For many here. the Pine Apple clinic is the only health-care facility they can reach or afford. The clinic has a sliding scale based on income. with the lowest ice at 37. If patients ca'n't pay. they don't have to. and since everyoneknows everyone. the clinic staff knows who can't and who won't pay. Many times, they pay with food. like Partin's sweet potatoes. One woman brought in a big tub of cooked oorn. "We just stopped everything arid everyone had some corn." Dr. cook recalled. -'I'he waiting-room atmosphere is more like a friendly community cen- ter than a doctor's office. Patients greet each other as friends. They swap gossip. One woman who loves peppermint candy hands cellophane- wiapped discs out to everyone in the room. People stroll through simply to see who?s there. {The clinic is more than a commu- nity center. Partln says. He opens his mouth to describe it. then snaps it stint with an embarrassed look. started to say something. but I'm not gain to." he says. l'The most irdportant log in the world is to have Jesus. I started to say. to have the clinic here in Pine Apple is the mint important thing. but it's not.? Hepausies. come that close. Can you tell how important it is to me?? i House cell i :Today. Dr. Cook is stopping by the disintegrating home of lia~year-old. wheelchair-bound Melvin Stallworth. any of her many favorite patients. He's suffering from a leg sore. and pr. Cook wants to change his dress- ing. She sips along in her new blue Cav- alier. which has 2t.DtiD.miles on it. pointing out where her patients live and describing their lives. She traded in her old hlue Cavalier. which rolled up 120.000 miles in three years driv- ing around Wilcox County. putside Stallworth's four~room. tin-roofed house. she pauses in play with Hess and Bessie. two mutls who raucously greet her. She gave the dogs to Stallworth. who lives alone. to keep him company. Someone had abandoned them near the clinic. f?Everyday I passed them and saw them getting a little bit skinnier and a little bit more scruffy. and 1 finally picked them up." she said. She regularly brings Stallworth a ??iwund bag of dog food so the dogs won't be a burden. '-'Thcre's a lot more to medicine." Dr; Cook will say later. "than pre- scriptinrls.? a wintry chill sweeps into the sit- tin'g room as Dr. Cook opens the door between it and his kitchen. "Still have this hole in the floor in here?" she asks over the suctiony sound of his "ice bait" pulling open. 1ir'es. he tells her. but his son. who lives down the road. plans to cover it with a piece of plywood. Some of his older leftovers go to the dogs ouLside. allowing Dr. Cook to settle down with the leg. She pulls supplies from her Sears bag and polls on plastic gloves in the room in which Stallworth sits about a foot from his small wood-burning stove. the house's only source of heat. A single light bulb glares from overhead. its on-olf pull string care- fully threaded to a tiny bed on the op- posite wall from the stove. it brace and trian ular-sliaped pull-handle above the ed allow Stallworth. who has a bad back and bad knees. to ma- neuver in and outoi bed. The room and its old furniture are littered with clothing and household debris- Only the stove is new. in- stalled by Stallwortb's son to replace an old ?dangerous"-model. Dr. Cook says. Staliworth got running water only in the last two years. she says. Stallworth dropped a piers of wood on his leg as he was trying. from his wheelchair. to fish a log out of his in- door pile for his stove- As Dr. ka peels back a plastic patch. the doctor clearly is alarmed at what she sees. The weeping wound. a bright pink and nasty yel- low. has spread to palm-size and seems badly infected. "It looks angry to me." she tells him. "it's gone into a [an in- fection of the skin} and it's spread." Cellulltis. he doesn?t understand. Angry. he does. "Has it been hurting?" she asks. "it keeps me company at night when lgo to sleep." he tells her. She cleans the wound and gently wraps it with dry gauze. While she does. Stallworth talks about his life as a sawmill worker. "Light never did see us home." he said. Dr. Cloak returned in the late after- noon to finish cleaning and bandagng the wound. "i didn't realize it had gotten this bad since the last time i saw it." she explains as she leaves in the morn- ing: "1 don't have the right tools." She tells him he needs an antihi- otic to fight the infection. and asks if anyone will be coming by who can pick up a prescription for him. His son and granddaughter check on him daily and regularly brin him meals. Not today. he says. hey're all at work or have some kind of appoint- ments. When she returns. she says. she?ll bring him some drug samples to tide him over. ?it feels better already. doc." he reassures her as she heads out. "i appreciate this old age. but I can?t hardly handle it." he says. Dr. Cook grins. ?it heals the alter- native. though. doesn't it?" As shr- will throughout the day. she repeats herself in simpler words. "it heals not growing old. doesn?t it?" she says. He grins at her and says. a little sadly. it little proudly. "Mighty few 1 in my crowd reached the ago i am." Doctor and community The Gracie Busse clinic serves 2.500 people like Stallworth. Ninety-seven percent of them are black. 3 percent white. Ninety-three percent have income below federal poverty levels. and 52 percent have no health insurance. They live precarious lives in many ways. but they seem to value basics such as friends. family and honesty more than people who have more money and things. Dr. Cook said. She has many patients older than 100. she said. and she believes it's be- cause they live in a true community. As with Stallworth. she said. kin of- ten live nearby and people look out for each other. "They're very much at peace with their lot. which is nothing fancy. In fact. by most people's standards. very poor. But they have very lasting relationships. deep faith and. with all that. I think there's a peacefulness that you just can't buy. 1 think that's the real secret of Christmas." Dr. Cook says. The annual orgy of the season an- noys her. "There's not anything Christ about it any more." she said. "It?s a pagan holiday all this buying and life. The real cause of Christmas has een lost. "They ought to change the name. because Christ has left it. or been left behind. I'm really not sure if He left it. or we left film behind." Dr. Cook seems at peace with the choices she's made. and she works in an even-keeled. kind manner that is both soothing and inspiring to those around her. She has the clean-scrubbed. no? nonsense look 'of a nun. with a wide toothy grin that splits her face when she smiles. Her- wide-rimmed glasses sit on a broad face framed by short-cropped blond hair. Her white doctor's coat tops an inexpensive navy blue outfit. Her mother and office workers swear she rarely gets angry. "i get angry when I see how inac- cessible our health care is." she says with feeling. "Our medical system is very prejudiced against the sick. For instance. when a person geLs medical disability. they can't work anymore. "Do you know how long it takes be- fore the program allows them to have Medicare? Twenty-four months. There's no way to buy health insurance with their little disability checks. but it's too much to get Medi- caid." Dr. Cook specialises in family riiedicine. the kind of primary-care practica that experts say must be emphasized to provide cost-effective health care in the Elsi century. These doctors. the experts say. spend less money on tests and catch health problems early. before they become expensive to treat. "You don't have to have a noplirn- logist {kidney specialist) for a di- abetic patient if the patient is kept under control." she says. Dr. Cook's Grace liussc Clinic. part of Selma-based iiural llcallh Medical Program lnc.. is one of more than 50 federally funded rural health clinics around Alabama. The Pine Apple clinic survives on a $300,363 budget. which includes all. expenses. including salaries for its staff of six. . The clinic tries to provide non-nar- any; . NEWS SIM-T HJOTOIJGE Frank Partin offers sweet because of the care she cotie prescription drugs to patients. Most are sarnples donated by drug companies. Many are forwarded by a fellow nun from a Tutwiler, Miss. clinic that's gotten lots of donations in the wake of national publicity. The federal government sends doc- tors to Wilcox County through its Na. tional Health Service Corps, which pays doetors? medical school tuition. The doctors agree to serve in rural areas for a few years to wurk'otf the tuition: the government hopes the doctors choose tostay. Some do. most don't, experts say. When Dr. Cook arrived, she re- olaced a Corns doctor who left with- out fulfilling his debt to the govern- n?it?mt1 she said. He kept short office hours and often would disappear be- fore he left for good. she said. "One of the first questions the pa? tients asked me when I came was how long are you going to stay. be- .eause there had been a succession of doctors." she said. didn't drive the government anything. I came out of need and plan to stay because u! the same reason." Livlng in hope alter the office staff takes a lunch break to celebrate the 32nd birthday of staff member Daisy Davis. Dr. Cook decides to check on Andrew Thomas. an 32-year-old patient who has heart trouble and He and his wife Lucille live in a trailer off a few dirt roads. It looks weathered from outside. with six tabby eats lolling all over the wooden porch. but inside it?s nicely paneled and very neat. . Mrs. Thomas opens the door. and her husband, a thin black man with potatoes and gallantry. Partin loves Dr. Cook. he said. gave his wife, who died of cancer. pmminent cheekbones and gray ha ir, is sitting on the bed in thermal un- derwear. With a trembling hand held over his heart, he describes how weak he feels. ain't doing good a'tall," he says. His heart is beating irregularly, she says with a worried look. The Thomases are watching a tele- vision news broadcast. They're very worried about the starving children in Somalia. Dr. Cook asks about Thomas's medicine and finds out that an antibi- otic seems ?fi make him feel had. She stops that medicine. increases an- other and asks if they can get to a drugstore today. They can't. Neither drive. and ?it's so hard to get somebody to do some- thing for you today." Mrs. Thomas Said. Dr. Cook says she'll get some- one lo bring it out from the clinic. Dr. Cook tells Mrs. Thomas to be sure that her husband is drinkinr: enough water and eating enough. If he doesn?t feel like eating a solid breakfast. she says. get him to drink a Carnation Instant Breakfast. "It has lots of extra minErals and vitamins in it," she says. also. she notes, it can be found easily in gro- cery stores. She listens to Thomas's heart a second time. "Well. I think it's settled down ?1 hit," she says. Mrs. Thomas gives her a hig hug as she leaves. "You come back real 5m". Mrs. Thomas asks. ?We do love our doctor. you hear what I'm saying? She really did bring him a long way." This is the .ttnd of thing that medi- See Nun. Page 25A 113 13.568. 4.203 white; 9.353 black. Population: Median household in- come: $12.43? Major industry: Forestry. Biggest industrial em- ployer: MacMihnn mouth-i; LEGO-2.000 mummy-nos. i) '1 rleH? Unemployment: power-- in (lemon.- an mare Most common causes of death: neon Illsense. cancer. stroke. acculents and Kidney problems. SUNDALDECEMBER so. 1992 - Nun THE BIRMGHAM NEWS FROM PAGE ONE PAGE 25 From Page 24A ral school students need to see. Dr toil-1 insists as she drives away. "They need to be exposed to an area like this and see how grateful people are. There's a lot of doctors who are burnt out because of the rat race." she said. "?l'hcy feel their patients are al? most their adversaries. They worry about lawsuits. They practice dev irnsive medicine. They have to mar- Lul their practice. i don't have to my practice. "They need to be exposed to how medicine can be. There's a tool art to medicine and it has many as? pools.? in 'l?homas's case. she said. felt going out to visit him and listen to him probably has made him i eel bet- than any medicine 1 could have si-nt back to him." tier presence. she said. helps coun- teract the feelings of helplessness and isolation site believed he was feeling hy reassuring him that help was there if he needed it. "One lives in hope." she said. Wilcox's problems Wilcox County's economic woes add to its health problems. Ixicated [?25 miles south of Bir- mingham. Wilcox County had the highest unemployment rate in the state. 12.3 percent. in October 1992. the last month tor which statistics are available. it w'as more than dou- hie the state's 6.1 rate that month .qu significantly more titan the na- tional 1.2 percent. The median household income in Wilcox County, meaning half are above it and half are below it. was $12.41?. according to the 1990 can- sus. That compares to $23,591 [or the state and 530,055 for the nation. Dr. Cook says many of her middle- aged potionts are illiterate because they either quit school to work or had to quit school to take care of family members while someone else worked. Poor people eat cheapEr load. which includes many fatty and high- sali items that add to blood pressure and diabetes problems. Dr. Cook and others say. Special diets are expensive and impractical for the poor. she notes. ?If you?re hungry. you eat. what you got." she said. The county's main industry is for- Accidents rank among the top five causes of death in Wilcox County. according to the state. Logging is one of the three most dangerous occupations, says Dr. Will Deal. associate dean of the UAB School of Medicine. He has visited Wilcox County and is familiar with its health care. No federal highways run through Wilcox County. only state and county roads. he notes. That creates prob- lems for patients getting to doctors and for nurses or ambulances getting to patients. Deal said. The county has several phone com ponies. so many calls perhaps to a doctor are long-distance, and many areas don't have running wa- ter. he said. And the school system is having problems. Many graduates are func- tional ililterates who can't fill out job applications, Dr. Cook said. That's a double whammy. she says. First. stu- dents are unlikely to learn much about health. and second. such schools can't help attract young doc- tors with families. Do the plus side. Deal said. Wilcox County's biggest industrial amp er. Canadian paper company Maeh'li lan Bloedel. generously supports the Camden hospital by buying expen- sive equipment for it. That's the sort of private support that rural areas will need in or or to attract proper health care. he said. That's nice. and gettin more pri- mary-care doctors to rura areas will help. Dr. Cook says. But more will have to be done. ?We're trying to Band-Aid ap- proach this thing. and I believe we're going to have to start all over from scratch." she said. The country must have national health insurance. or the gap between haves and have-nuts will only widen. she said. "There's no money. no insurance. on acorns and this is not just Wilcox County." Dr. (tool: said. "This is throughout the nation. ?We have rationed health care in our countr . Nobody should question that. You list go to a doctor's office without an hindrance carmnd you'll find out how much it's rat ed.? Simple lifestyle The Grace Basso Clinic is named [or a Florida woman whose husband sent small donations to the clinic alter reading a brief mention about it in McCall's magazine. The first $l0tl donation came addressed simply to ?Dr. Cook. Pine Apple. Ala." When Mrs. Busse died from cancer in her husband. John. wanted to help the clinic. What the clinic really needed. Dr. Cool: told Busse. was a new bathroom. "But i also told them I wasn?t sure that they wanted a plaque up that said. 'Gracc Busec Memorial Baths roorn.? Dr. Cook said. Instead. Busse uttered 550.0% to remodel the clinic building. including new bathrooms for patients and stall. He died before he could see the re- sults. Photos of the couple hang in the entrance hall. incidents like the Busse donation convince Dr. Cook that Americans want to care for their but they don?t know how. Dr. Cook plans to stay in Pine Apple until she retires or dies. she said. and she doesn't plan to do either at age 55. "I've witnessed the wonderful taith of the people I'm taking care oi. They have a goodness about them. in spite of all the obstacles. The cheerfulness and thankfulness they express it's really very reward- ing." she said. To a person. her patients credit Dr. Cook and the Lord with keeping them going. She laughs at being mentioned in such corn ny. "l'rn gla they put the Lord in there. because l'm Sure the Lord is doing more titan i am." she says. She does [eel pressure sometimes. she says. but "the gratitude helps rc? inlorco why i'm here in the first place. When i feel these echoes. 1 tool like. 'ycs. lord. l'm doing what You want me to do.? and that's a real blessin Dr. Emir is paid by the agency she works for She lives on a budget of ?.000 a year and said she sends the rest to her religious order in St. Louis. Site laughs at the notion that st could or should ?r keep more. ?i prefer continuing the way am." she said. "1 don't have time go shopping. You need food. shell- and a peaceful heart. You not friends and companions. "i think people who put their hog in things will always be dissatishe That's why they always need to_hu things. People who are content with simple life are far more happy." 114 APPENDIX WILCOX COUNTY PHONE LIST Physicians Sumpter D. Blackmon, MD. Po. Box 699 Camden, AL 36726 (205)682?4123 Roseanne Cook, MD. PO. Box 6, Hwy. 59 Pine Apple, AL 26768 (205)746-2197 Dr. Moskovich Rt. 1, Box 199 Pine Hill, AL 36769 (205)963?4201 James D. Nettles MD. 900 Main St. Arlington, AL 36722 (205)385-2285 Willie E. White, MD. 319 McWilliams Ave. Wilcox Medical Clinic Camden, AL 36726-1610 (205)632-4224 Health Department Wilcox County Health Dept. 209 Caldwell St. PO. Box 547 Camden, AL 36726 (205)682-4515 Sarah Evans, RN. Robert Jones, Sanitarian Bobbie Rush, W1C 115 Hospital 1. Paul Jones Hospital 313 McWilliams Ave. Camden, AL 36726 (205)632-4131 Arden Chestnut, Administrator Wendy Pearson, Med. Rec. Ext. 15 Health Centers Community Health Center of West Wilcox County (Alberta Clinic) PO. Box 97 Hwy. 5, Wilcox Co. 29 Alberta, AL 36720 (205)573-2493 Maureen Nichols, Nurse Prac. Pine Apple Medical Center Hwy. 59, PO. Box 6 Pine Apple, AL 36768 (205)746-2197 Dr. Cook Vredenburgh Clinic PO. Box 494 Vredenburgh, AL 36481 (205)337-4787 Sister Pat Hauser, RN. Sister Mary Rouleau, Ed. Center Yellow Bluff Med. Center Rt. 1, Box 199 Pine Hill, AL 36769 (205)963-4201 Dr. Moskovich Kellogg Project Sheryl Threadgill, Coordinator-Wilcox Kellogg Project P.0. Box 430 Camden, AL 36726 (205)682-42 3 Joy Skantz, RN (205)682 4302 Linda Bibb, Coordinator-Lawndes (205)548?25 16 UAB International Health (205)934-1732 Dr. Walter Mason Dr. Charles Stephenson Dr. Pauline Jolly International Health Laboratory (205)934-0450 Dr. Carol Hickey (205)934-7161 Vee Stalker (205)934-3262 Alabama Tomhigbee Regional Com. John Clyde Riggs Courthouse Annex Box 269 Camden, AL 36726 (205)682-4234 FAX (205)682-4205 Wilcox Co.Commisioner's Of?ce Mr. Bobby Joe Johnson PO. Box 488 Camden, AL 36726 115 Schools Wilma Co. Board of Education PO. Box 160 Camden, AL 36726 (205)682-4178 Arlester McBride. Superintendent Mary Whiting, Chapter 1 Nurse (205)682-4922 Edna Richardson, Special Ed. Nurse (205)632?4716 Catherine Academy (205)225-4401 Wilcox Academy (205)682-9616 West Alabama Health Services Transportation (Mr. Armstead) (205)289-5789 Payroll (Shirley or Lucille) (205)372-4770 Montgomeg Center for Health Statistics (205)242?5033 Epidemiology (205)242?5131 Rural Health Initiative [Selmal Evelyn Merritt (205)874-2428 10. ll. 12. BIBLIOGRAPHY Wise, P. and Meyers, A. "Poverty and Child Health." 771a Pediatric Clinics of North America, Vol. 35, No. 6, pp. 116982, December 1988. Klerman, L. Alive and Well? A Research and Polig Review of Health Programs for Ygung Children, National Center for Children's Poverty, Columbia University, School of Public Health, p. 25, 1991. Sedmshaw, S. and Hurtado, E. Rapid Assessment Procedures for Nutrition and Primarv Health Care: Approaches to Programme Effectiveness. The United Nations University, Tokyo, Japan, p. 2, 1987. Parks, D. and Bailey, S. "The poverty line." The Birmingham News. pp. 1A, 12A, April 4, 1990. Ho, L., Glass, R., Pinsky, P., Young-Okoh, N., Sappen?eld, W., Buehler, J., Gunter, N., and Anderson, L. "Diarrheal Deaths in American Children--Are They Preventable?", Joumaf of the American Medical Association, Vol. 260, No. 22, pp. 3281-85, Dec. 9, 1988. Dover, C., Holley, H., Iarecki-Blaek, J., and James, E. ?ve-year study of intestinal parasites in Charleston, South Carolina." The Journal of the South Carolina Medical Association. Vol. 82, No. 5, pp. 327-31, May 1986. Hall, A. "Nutritional ASpects of Parasitic Infection." Progress in Food and Nutrition Science, Vol. 9, pp. 227*56, 1985. Gupta, M. "Effect of ascariasis upon nutritional status of children.? Jonrnoi of Tropical Pediatrics, Vol. 36, pp. 189-91, August 1990. Kvalsvig, ., Cooppan, IL, and Connolly, K. "The effects of parasitic infections on cognitive processes in children.? Annals of Tropical Medicine and Parasitology, Vol. 85, No.5, pp. 551-68, 1991. Nabbefeld, I. "Thousands in state yearn for privilege of water lines." The Birmingham News, pp. 1A, 12A, Feb. 9, 1992. Howard, J. "33% of Alabama moms miss out on prenatal care," Birmingham PQg-ngalgl. 1). A1, A10, September 10, 1992. Alabama Department of Public Health and the Center for Demographic and Cultural Research. Alabama Health Data Sheet. Auburn University, Montgomery, Alabama, September 1992. I3. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. Alabama Department of Economic and Community A??airs. 15th Edition: Alabama Counm Data Book. March 1991. Bureau of the Census. 1990 Census ofPopulatign and Housing. Summary of Social, Economic, and Housing Characteristics, Alabama. US Department of Commerce, Washington, DC, pp. 17, 83, 1991. Kanamine, L. "Amid Crushing Poverty, Glimmers of Hope, USA Today. p. 7A, November 30, 1992. Butgereit, B. "More than prescriptions." The Birmingham News, pp. 1A, 24A, 25A, December 20, 1992. Johnson, F. Phone Interview, Alabama State Board of Education, September 10, 1992. Plott, B. "Wilcox County school system's woes are legion." The Birminghm News, pp. IA, 10A, August 29, 1992. Benn, A. "Teague to control Wilcox schools' hiring, spending." The Montgomery Adveniggr, pp. 113, 2B, September 3, 1992. "Wilcox test scores still the lowest." The Wilcox Progressive Era, Vol. 133, No. 53, December 30, 1992. ?Wilcox County Commission. Fiscal Year '92 Application Water Line Extension Project Single Purpose Program, Wilcox County, Alabama, State of Citiestommunity Development Block Grant Program, April 13, 1992. Alabama-Tombigbee Regional Commission. Sewage System Planning Report Wilcox County." Department of Housing and Urban Development and the Alabama Department of Economic and Community Affairs, p. 12, Fiscal Year 1990. Town of Vredenburgh. Community Development Block Grant, 1992 Special Fund Application, Galbraith Associates, April 30, 1992. Rothenberg, R., Lobanov, A, Singh, K., and Stroh, G. "Observations on the application of EPI cluster survey methods for estimating disease incidence." Bulletin of the World Health Organization, Vol. 63, No. 1, pp. 93-99, 1935. 1'18 25. 26. 27. 23. 29. 30. 31. 32. Henderson, R. and Sundaresan, T. ?Cluster sampling to assess immunization coverage: a review of experience with a simpli?ed sampling method.? Bulletin of the World Health Organization, Vol. 60, No. 2, pp. 253-60, 1932. Jones, J. "Identi?cation of intestinal parasites in an of?ce setting: A comparison with a reference laboratory." Family Practice, Vol. 3, pp. 148-54, 1984. Jones, .1. "Identi?cation of Intestinal Nematodes Using the Digital Rectal Examination.? The Journal of Family Practice, Vol. 12, No. 3, pp. 563-65, 1931. Mantel, N. and Haenszel, W. "Statistical aspects of the analysis of data from retrospective studies of diseases." Joumal of the National Cancer Institute, Vol. 22, pp. 719-48, 1959. Greenberg, R. and Kleinbaum, D. ?Mathematical modeling strategies for the analysis of epidemiological research. Amara! Review afPulJlt'c Health, Vol. 6, pp. 223-45, 1985. Listernick, R., Zieserl, E., and Davis, T. "Outpatient Oral Rehydration in the United States." American Journal of Diseases of Childhood Vol. 140, pp. 211- 15, March 1936. Kappus, K., Juranek, D., and Roberts, .1. "Results of Testing for Intestinal Parasites by State Diagnostic Laboratories, United States, 1987." National Survey, Vol. 40, pp. 25-45, 1988. Alabama Department of Public Health. Ngti?able Diseases in Alabama 1990, Appendix, 1990. 119