Appendix D1 - D5

Appendix D1 Introduction to Case Studies

D1.1 Purpose of This Project

Syphilis prevention efforts by the US Centers for Disease Control and Prevention (CDC) are guided by science-based, community-oriented, culturally specific strategies. Our current project aims to help with these prevention efforts by examining past and current responses of the public and private health sectors, and of communities themselves, to the epidemic of early syphilis in the southern states since 1988. The project focuses on people perceived to be at highest risk for syphilis infection, the extent to which public health activities target such a category or group, and to what effect. It also aims to uncover innovative approaches to primary prevention and the cultural sensitivities that can affect the success of interventions.

We selected four southern states for a comparative case study: Alabama, Mississippi, South Carolina, and Tennessee.

D1.2 Background

From the mid-1980s to the early 1990s, early syphilis morbidity has been reported disproportionately in the southern US, particularly among African-American populations. Figure D.1 shows the national trend for reported cases of primary and secondary syphilis by race and ethnicity from 1981 through 1991. Syphilis rates increased across the US from 1986 through 1990, beginning to decline in 1991 in all regions except the Midwest. The highest rates of syphilis were found in the southern states throughout this period. In 1991, the highest rates of primary and secondary syphilis were reported from: Louisiana (70.0 cases per 100,000 population), Mississippi (48.0), Georgia (45.6), South Carolina (43.8), and Alabama (39.4) (US PHS, CDC, 1992).

In 1981, all but two of ten southern states had syphilis rates higher than the Year 2000 objective (10 cases per 100,000 population). States in other regions of the country were closer to achieving this objective: less than one-half of the northeastern states exceeded the Year 2000 objective, while only one-third of the midwestern states, and no states in the west exceeded this objective.

High morbidity continues in the South. As Table D.1 shows, by 1993 only one southern State (Florida) was at or below the Year 2000 objective. African Americans, particularly in the South, have suffered a disproportionate burden of early syphilis and its adverse outcome, congenital syphilis. In 1993, the rate for African Americans was almost 62 times greater than for whites.

CDC has supported state-based syphilis prevention programs by providing grant awards and personnel resources to state and local health departments for more than 30 years. CDC's support has aimed to bolster clinic-based case detection, treatment, partner notification, and other prevention activities. High syphilis morbidity rates persist, however, despite these measures.

D1.3 Site Selection

We chose Alabama, Mississippi, Tennessee, and South Carolina for case studies because they represent a cross-section of public health administrative jurisdictions in the South. In each state a major metropolitan area is paired with a rural counterpart to enable an urban/rural comparison of social contexts and public health activities.

Specific site-selection criteria included:

• Syphilis epidemiology. Based either on consistently high rates since 1990, or on rates that have shown an interesting decrease, a pair of urban and rural counties have been matched in four states (Table D.2).
• Social demography. The selected counties each have a relatively high proportion of African-American residents and a high proportion of households with incomes below the poverty level. Reported cases of syphilis are highest among African Americans, and those thought to be at highest risk for syphilis infection include low-income residents.
• Geography. We considered location with respect to transportation corridors to be important because of the possibility of movement between rural areas and urban areas for employment, entertainment, or other opportunities for social interaction involving persons at high risk for syphilis infection. Epidemiological evidence of disease transmission was found to be more important than administrative units (e.g., state boundaries). Thus, one region of interest is the Mississippi Delta, which cuts across metropolitan Memphis, Tennessee, and the northwestern counties of Mississippi.

D1.4 Data Collection and Analysis Methods

Background information about each of the sites was obtained through a review of published literature and unpublished agency reports and planning documents. A series of week-long site visits was also conducted. Between 40 and 60 persons were interviewed in each locale, representing public, private, and community-based health care providers, community-based organizations (CBOs), and community members.

Open-ended interviews produced information about:

• Who is at greatest risk for syphilis transmission and infection,
• What institutions are best able to reach these individuals,
• What barriers stand in the way of reaching at-risk individuals with these institutions, and
• Any innovative activities that prevention programs in other sites would benefit from knowing about.

Field notes were entered into a text-oriented database management system (The Ethnograph). Interview notes were coded according to specific themes. Two independent coders were used to protect reliability. Topical reports were then generated from the coded text and used to produce a descriptive case study for each state. Through these summaries we noted where patterns and divergences among the individual cases emerged and developed rival hypotheses for use in the generation of models for improved syphilis prevention and control.

All information gained from these interviews has been treated as strictly confidential. No comments or quotations are attributed to individual respondents. Raw interview data are not to be shared with CDC or with others outside the project staff.

D1.5 Case Study Organization

Each of the case studies in this appendix is organized in the same manner:

• Section 1 Community profiles. Section 1 of each case study provides geographic and demographic descriptions of the two sites. Information on other social indicators, such as employment and education, prominent institutions, and health care issues that further develop the communities' profiles are also included in this section of the report.
• Section 2 Key assessment issues. Section 2 of each case study highlights key assessment issues, as judged by a variety of public and private health care providers and community individuals, concerning:
  • Who is at greatest risk of acquiring/transmitting syphilis,
  • What community institutions are capable of reaching these populations, and
  • What facilitators or barriers exist in bringing effective prevention to these populations.
• Section 3 Innovative strategies. In Section 3 of each case study we offer examples of innovative prevention and control strategies either already in place or in well-advanced planning stages.

Case study reports have been produced for:

• Hinds (Jackson) and Humphreys counties, Mississippi (pilot study,Section D2)
• Richland (Columbia) and Orangeburg counties, South Carolina (Section D3)
• Shelby County (Memphis), Tennessee, and Tunica County, Mississippi (Section D4)
• Montgomery and Lowndes counties, Alabama (Section D5).

Appendix D2 - Case Study of Hinds and Humphreys Counties, Mississippi

D2.1 Community Profiles

A pilot study was conducted in two Mississippi sites: Hinds County (urban) and Humphreys County (rural).

D2.1.1 Hinds County (Jackson) Urban

Geographic Characteristics

Jackson is the largest city in Mississippi; in 1990 its population was 196,637. However, the central city itself is growing smaller, while the rest of the Jackson metropolitan area (Hinds and Madison Counties) is expanding. The 1990 metropolitan area population of 395,396, an increase of 9.2 percent over the previous decade (US Bureau of the Census 1994a).

Demographic Characteristics

The city of Jackson was about 56 percent African American and 44 percent white in 1990, with small groups of Hispanics, Asians and Pacific Islanders, and American Indians. The metropolitan area as a whole was about 42 percent African American and 57 percent white in 1990. Between 1980 and 1990, Hinds County grew by 1.4 percent. However, the county saw a 10.6 percent decrease in the white population and a 14.4 percent increase in the non-white population. At the same time, there was a 63.2 percent increase in the white population in neighboring Madison County. The area's white residents have been moving north into new suburbs in previously rural areas in Madison County an area around County Line Road, where new malls, businesses, restaurants, and other public infrastructure are being built. The African-American middle class has been moving into the Jackson suburbs abandoned by the whites. This leaves Jackson's central city with a limited economic base and with a population that is poor, largely African American, and vulnerable to problems of unemployment, crime, drug abuse, and gang activity.

Economic Characteristics

Per capita income in Jackson was $12,216 in 1990, with almost 23 percent of the population falling below the poverty level. While in Hinds County as a whole the median family income is $30,125, an income disparity can be seen when this number is separated by race. In the county, the median family income for whites is $41,636, while for African-American families it is $18,316 (Howell et al. 1995:138). The major employers in the Jackson area are the federal, state, and local governments; Jackson Municipal Separate School District; University of Mississippi Medical Center; Mississippi Baptist Medical Center; South Central Bell Telephone Company; Jitney Jungle Store of America (a grocery chain); Mississippi State Hospital; McRaes, Inc.; Packard Electric; and Rankin County Superintendent of Education (Barlow and Wasserman 1992:225).

As the list of major employers shows, Jacksons medical complex is extensive and an important part of the local economy. There are eleven hospitals in Jackson, with 2,294 beds (Barlow and Wasserman 1992:227). The rate of hospital beds per 10,000 population in Hinds County is more than double the national rate, and with 1,005 physicians as of 1988, the physician rate per 10,000 population (39.6) also exceeds the national rate (20.5) (Mississippi State University 1991).

Jacksons geographic location makes it a major commercial distribution center, situated half way between Memphis and New Orleans on Interstate Highway 55 and between Dallas and Atlanta on Interstate Highway 20. The city is 45 miles east of the Mississippi River, and 145 miles north of the Gulf of Mexico. Because of its history as the commercial center of an agricultural state, many people in Jackson continue to have strong economic and family ties to the rural areas. In the minds of many residents of the city, Jackson is still seen as a small town that is just beginning to experience some of the problems of an urban center.

Social Characteristics

Jackson is reported to have some of the worst inner-city housing conditions in the entire country. In the areas of the city that are the most economically disadvantaged and have the highest population density, up to 10 percent of the housing is substandard or abandoned. Jackson is filled with pockets of shotgun style houses in dilapidated condition, often available for as little as $5,000 each, and mostly owned by absentee landlords.

The west side of Jackson is where the areas with the worst economic conditions and housing are located. Some of these areas include the neighborhoods around Jackson State University, Georgetown, Midtown, and Farish Street, the historical African-American business district.

Because of its location, Jackson is also a distribution center for illegal drugs being transported from the Gulf of Mexico to urban centers in the north. Jackson has had an epidemic of crack cocaine usage since the mid-1980s, and crack addiction has led to many other social and public health problems. In addition to increases in crime by crack addicts seeking money for drugs, local public health officials believe prostitution and sex-for-drug transactions have also increased dramatically. These activities, which often take place in hourly motels and crack houses, expose crack addicts to high risk for contracting and spreading STDs such as syphilis.

The Jackson metropolitan area is divided into seven public school districts, and another 50 private schools operate in Hinds and Madison counties. Post-secondary institutions include Hinds Community College, Jackson State University, the University of Mississippi Medical Center, and several private colleges: Belhaven College, Millsaps College, Mississippi College, Reformed Theological Seminary, and Tougaloo College.

While the church is seen as a very powerful institution throughout the state of Mississippi, there is little evidence of its involvement in efforts to raise public awareness of effective approaches to controlling substance abuse or the spread of sexually transmitted diseases. Jackson has more than 400 churches, and it is said that there is a church on every corner in the rural areas; however, conservative Bible Belt standards appear to prevent churches and many institutions from directly addressing these controversial issues.

Other organizations in Jackson are directing efforts towards substance abuse and disease prevention and control. Some of these include the American Red Cross, the New Hope Foundation, Operation Shoestring, the Mississippi Children's Home Society and Family Services Association, drug abuse treatment centers in some of the local hospitals, and University-based organizations such as the Jackson State University Community Health Program and the Urban Community Service Project.

Health Care

In the Jackson metropolitan area, health care is available to low-income residents mainly through the Mississippi State Department of Health (MSDH) and through Jackson/Hinds Comprehensive Health Center (JHCHC).

MSDH operates several clinics in the metropolitan area, and its Ellis Avenue (HIV/STD) clinic began seeing patients in July 1995. Ellis Avenue is funded as part of the CDC Syphilis in the South grant program. The Disease Intervention Specialists (DIS) serving the Jackson metropolitan area are now based out of the Ellis Avenue facility. Plans were under way to increase the seven DIS currently working in the Jackson metropolitan area with up to seven more federal assignees through the use of CDC Public Health Advisors, and to institute management practices (e.g., explicit performance expectations) that aim to enhance the quality of disease intervention efforts.

JHCHC currently operates satellite clinics throughout the Jackson metropolitan area and is the main source of health care for low-income African-American residents. JHCHC offers a full array of primary care and dental services and through 1995 conducted HIV prevention education throughout the community, with funding from MSDH. JHCHC is also finalizing plans to renovate and occupy an abandoned shopping mall that is centrally located for much of the population from which it draws its patients. The mall will house health care services from cooperating agencies such as JHCHC, Hinds County Health Department, Univeristy Medical Center, Jackson State University, and Tougaloo College.

Jackson metropolitan area residents seek health care in a variety of locations. Many low-income patients go to the Emergency Room of the University Medical Center. The federal Department of Veterans Affairs operates a large medical center in Jackson, which has a dedicated patient population (military veterans and their eligible dependents) that, although somewhat older, includes some HIV+ and syphilis-infected persons. Among the physicians with private practices in the area, one prominent African American was singled out as providing services to households in the neighborhoods that were also mentioned as locations for high-risk activity. Medical screening among inmates in the state and local corrections institutions was not mentioned in any of our discussions.

D2.1.2 Humphreys County Rural

Geographic Characteristics

Humphreys County is approximately 50 miles north of Hinds County in the heart of the Mississippi Delta. The County is intersected by Highway 49W and is in the historical cotton-growing region of the Yazoo River Delta.

Demographic Characteristics

The population of Humphreys County was 12,134 in 1990, about 68 percent African American and 32 percent white. From 1980 to 1990, Humphreys County had a population decrease of 12.9 percent, including a 22.4 percent decrease in the white population and a 10.1 percent decrease in the non-white population (Howell et al. 1995:18). From 1940 to 1990, the population of Humphreys County decreased by 53.8 percent, partly because of increasingly automated cotton production.

Economic Characteristics

The economy of Humphreys County is dominated by agricultural production and food processing. With its county seat in Belzoni, Humphreys County is known as the Catfish Capital of the World. Over 80 percent of all catfish consumed in the US is produced on massive catfish farms in Humphreys and neighboring Delta counties, and an Annual World Catfish Festival is held in Belzoni every April. The other main industry in Humphreys and surrounding counties is cotton production. The city of Greenwood, in neighboring LeFlore County, proclaims itself the Cotton Capital of the World. Due to the dominance of cotton and catfish production in Humphreys County, employment choices and economic opportunities are limited. For example, in northern Humphreys County the main source of employment is the catfish processing plant in Isola, owned by Country Skillet, a subsidiary of food conglomerate ConAgra. Most of the jobs at the plant pay the minimum wage of $4.25 per hour, with no increase for overtime worked, and no benefits. People who do not wish to work there, or in the cotton industry, are left with very few employment options. The unemployment rate in Humphreys County in 1988 was 15.5 percent. When separated for race, the unemployment rate was 2.8 percent for whites and 25.7 percent for non-whites (Campbell, Gilbert, and Grimes 1992:136).

Nearly one-half the residents in Humphreys County live in households with incomes below the poverty level (Howell et al. 1995:138-139). There is a strong income disparity when observed by race. For example, while the median family income for whites is $27,083 in Humphreys County, for African-American families it is $9,350 (Howell et al. 1995:138). Also, of the people in Humphreys County below the poverty level, 91 percent are African American (Mason 1992).

Social Characteristics

Educational achievement in Humphreys County is well below state and national averages. As of 1990, the number of persons over 25 years of age who had a high school diploma or equivalency was only 1,336, and the number who had a college degree was 951 (Howell et al. 1995:126). Although 68 percent of the population in the county is African American, 60 percent of the college degrees are held by whites.

Another important social indicator for Humphreys County is that 33 percent of all households are headed by unmarried females. Only 9.8 percent of white households are headed by single females, while 47.8 percent of non-white families are female headed (Howell et al. 1995:114). This situation is similarly reflected in most of the counties of the Mississippi Delta.

Crime, gangs, and drug use are reported throughout the county. People move back and forth between Mississippi and northern cities such as Chicago and Detroit, and the introduction of gangs and crack cocaine to the Delta is said to have followed these movements. Symbols of a well-known Chicago gang, the Gangster Disciples, can be seen in towns as small as Isola (population 732).

Drugs, specifically crack cocaine, are known to move between the towns along Highway 82 and Highway 49. These localities, such as Greenwood, Indianola, Yazoo City, and Greenville are connected by the transport of crack cocaine; they also exhibit a high rate of syphilis infection.

In Humphreys County and other rural areas, not as many organizations have been formed to deal with the problems of drug abuse and STDs. For the treatment of drug addiction, rural residents must travel to urban centers such as Jackson or Greenville, and the availability of services is limited even in these places. The treatment, control, and prevention of sexually transmitted diseases is the sole responsibility of the Health Department in the rural areas, although there is cooperation with local clinics and private medical practitioners.

Health Care

Humphreys County is one of nine Delta counties in Public Health District III. The administrative offices of District III are in Greenwood, Mississippi, in LeFlore County. The other counties of District III are Attala, Bolivar, Carroll, Holmes, Montgomery, Sunflower, and Washington. The Health Department clinic for Humphreys County is located in the town of Belzoni, the county seat.

In Belzoni, there are also two family practice clinics run by private physicians and the Humphreys County Hospital. The two physicians with private clinics are attending physicians at the hospital. In September of 1995, the Humphreys County Hospital opened the Main Street Clinic in the small town of Louise. This clinic was opened to offer medical services to the residents of Louise with difficulty finding transportation to Belzoni and to draw patients away from unnecessarily using the emergency room at the hospital in Belzoni. The clinic is staffed by another doctor, who is also an attending physician at the hospital in Belzoni, and by a nurse from that hospital.

In Isola, another Humphreys County town, medical services are offered at the Community Health Clinic. The clinic in Isola is run by a registered nurse and offers services such as medical screenings, lab work, patient exams, STD testing, and treatment of hypertension and diabetes. A pediatric nurse practitioner comes into the Isola clinic to offer services, and a full-time physician was expected at the end of November. The clinic also offers services on two Saturdays per month, and evening hours are being considered. In this clinic, and in the private clinics in Belzoni and Louise, all cases of syphilis are reported to the Health Department, and the patients are referred to the Health Department clinic in Belzoni and to the DIS.

Even though the rural population of Humphreys County is geographically dispersed, health care is available in the small towns. Payment does not seem to be a problem, because a very large percentage of the population receives Medicaid or Medicare benefits. One barrier to health care access has been the lack of transportation for the elderly, but with the recent introduction of physicians in Isola and Louise, this problem seems to be somewhat alleviated. Another barrier to care is the lack of high-tech medical services or specialists in the County. With the large elderly population, the demand for dialysis services is rising. We were told, however, that patients have to travel to Indianola or Greenwood for the nearest dialysis services. We were also told by local health care providers that prenatal services are lacking in Humphreys County. Concerns were raised about the quality of services at the Humphreys County Hospital. We were told that the hospital is known locally as the band-aid station, and a local saying has it that if you are two minutes from death it is better to drive the hour to Jackson.

D2.2 Key Assessment Issues

D2.2.1 Who is at greatest risk of acquiring/transmitting syphilis

The factors thought to contribute to heightened risk of syphilis infection are somewhat different in urban and rural areas. In addition, among respondents, views concerning risk factors are influenced by their confidence in the reporting system and by how clearly they distinguish between syphilis and other sexually transmitted diseases.

Reported cases of early syphilis, in both the urban and rural Mississippi settings, almost exclusively involve low-income African Americans. Public health agency staff feel that the morbidity statistics reflect some bias, however, because they believe that many white residents turn to private physicians for treatment, rather than to public health clinics. Although private physicians are required to report a syphilis diagnosis, they are suspected of providing an official diagnosis of a more general nature, treating their patients without laboratory tests, and thereby getting around reporting requirements.

Syphilis is not the most prevalent sexually transmitted disease in either the urban or rural setting, but the risk factors associated with syphilis were more clearly distinguished from other STDs by health care providers and public health agency staff. Representatives from community-based organizations, school districts, social service agencies, substance abuse treatment facilities, and so forth do not talk as precisely about differences between syphilis and other STDs. Unprotected sex and multiple sex partners increase the risk of becoming infected with an STD, and differences are glossed over between exposure to syphilis, gonorrhea, chlamydia, and, in recent years, even HIV. Below we discuss specific risk factors identified by respondents, first in the urban, then in the rural site.

Hinds County (Jackson) Urban

Substance abuse. In the metropolitan Jackson area, public health officials single out the use of crack cocaine as an important risk factor for syphilis infection. Crack is highly addictive, and although the cost for a single high is relatively modest, the high is short-lived. Users quickly run through their resources and turn to theft, robbery, check fraud, and exchanging sex for drugs or for drug money. One ongoing data collection effort reported that in a recent year, female crack users now in treatment had an average of 130 sex partners. A distinction is made here between people (usually, but not exclusively, women) who trade sex for crack and prostitutes, commercial sex workers who are said to take better care of their health e.g., receive more regular testing for STDs" because their ability to charge more for their services depends on it. Male drug users who provide crack to women (and to men, it is reported) in exchange for sex may be important nodes in sexual networks, but they are highly inaccessible to public health agencies. While many people involved in the crack trade eventually come into contact with the criminal justice system, we did not hear anything about public health screening in correctional facilities that is aimed specifically at providing a clearer picture of drug users and their possible role in transmission dynamics.

The local areas where crack dealing, crack houses, and prostitution occur are well known to public health agency staff, as are the times of the day and the days of the week when activities are likely to be at their greatest.

Age. Individuals treated in the urban setting for syphilis infections are usually in their mid-20s to late 30s, a little older than those treated for gonorrhea and chlamydia. Due to the connection with crack use (and a user population that includes teenagers and younger adults), public health officials note that the average age of those treated for syphilis has decreased. Teenagers, because they regard themselves as invulnerable and appear not to be protecting themselves or limiting the number of sexual partners, are expected by some to constitute a growing proportion of syphilis cases. However, if teens are mainly having sex with people about their own age, the chances of becoming infected with other STDs are greater than the chances of becoming infected with syphilis. Those who work with teenagers feel that getting teenagers to change their behaviors is especially difficult.

Gender. About equal numbers of males and females are treated for syphilis infection in the urban setting. However, some observers feel that females especially are at risk for syphilis infection if they are sexually active, even if they are only involved with one partner. This is because their male partner may be involved in more than one sexual relationship at a time. As it was explained to us, while women in such circumstances do not necessarily want to be involved with men who also have other partners, they feel that they gain something of material benefit from these relationships. The men refuse to wear condoms, and the women comply with their partners wishes for fear of losing them.

Sexual orientation. Differences of opinion surfaced about syphilis morbidity in the urban setting among men who have sex with men. Information is not systematically recorded about the sexual orientation of infected persons. Regardless of the actual incidence of disease, however, a general consensus emerged that many African-American men have sex with other men without self-identifying as gay or bisexual. Men having sex with men but not self-identifying as gay are seen as particularly difficult to reach with risk-reduction and health promotion messages.

HIV and other STDs. Those at greatest risk for becoming infected with syphilis are not seen as overlapping significantly with those at greatest risk for HIV infection. Public health staff report that syphilis is not seen frequently among those infected with HIV, and HIV is seen only rarely among those treated for syphilis. The fastest growing category of new HIV cases involves heterosexual transmission to women. However, DIS staff in particular feel that HIV has not yet arrived in Jackson in large enough numbers to reflect that emerging pattern. Their feeling is that the same risky sexual behavior that leads to syphilis and other STDs will eventually place people at risk for HIV.

Repeat infections. In the Jackson metropolitan area, patients with repeat syphilis infections are reported infrequently. DIS staff suspect that drug dealers are among those most likely to be infected repeatedly, but say that it is often too dangerous to pursue contact tracing and treatment with dealers.

Humphreys County Rural

Substance abuse and age. In Humphreys County, use of crack cocaine is cited as an important risk factor, but patterns of sexual relationships among teenagers are also mentioned prominently. Humphreys County is connected with a major drug distribution route nearby. As mentioned earlier, connections to Memphis and even gang activity in Chicago and Detroit are evident in small Humphreys County towns. Young people are becoming sexually active at a very young age, and many are dropping out of school before they get to the grade levels where sexuality and STD prevention are introduced into the health education curriculum. The dearth of recreational opportunities for youth is also said to lead to risky teenage sexual activity.

HIV and other STDs and repeat infections. We were told by public health department representatives that about 90 percent of those treated for STDs in Humphreys County are treated for repeat infections. Most of the repeat infections are gonorrhea or chlamydia. However, we were told that about 30 percent of the syphilis cases treated at the Health Department clinic are repeat infections.

Commercial sex work and trading sex for drugs. As in the urban setting, the locations where high-risk activities occur are well known; commercial sex work is uncommon in Humphreys County, but trading sex for drugs is part of the crack scene. The recent introduction of the riverboat casinos a short drive away is not seen as having a significant effect on STD morbidity in the area.

D2.2.2 What institutions are thought to be most likely to reach those at greatest risk

Health Department. The Mississippi State Department of Health (MSDH) is organized into a State Board of Health, a State Health Officer, programmatic and administrative personnel at the central office in Jackson, and nine geographically based Public Health Districts, each made up of multiple counties and headed by a District Health Officer. Each District Health Officer is responsible for the county and local health department offices and clinics within the District, the operations of the Disease Intervention Specialists (DIS), and all district-level administrative and programmatic operations.

Hinds County, which contains the capital city Jackson, is an exception to the district-level organization. Hinds County was part of District V until 1995, when it was made its own separate Public Health District. The main reason for this separation is the population density of the County. One result of this density is that while 40 percent of the syphilis cases in Mississippi are observed in District V, 75 percent of these cases are found specifically in Hinds County.

Within the programmatic and administrative offices of the Health Department, the HIV and STD divisions were combined on April 1, 1995. The Division of HIV/STD has four branches: Education and Prevention, Care and Services, Field Operations, and Surveillance.

Greenville, in Washington County, is the third largest town in Mississippi and has the highest syphilis rates in the state. The public health workers in District III report having a difficult time keeping up with the spread of sexually transmitted diseases such as syphilis, which they link to the rapid introduction and spread of crack cocaine into Greenville and a corresponding increase in transactions involving unprotected sex-for-drugs. In Humphreys County, the Health Department clinic is in Belzoni. District III has nine DIS, and except in situations of overwhelming workload, the senior DIS, based in Greenville, is responsible for Humphreys County. He is well known and respected by people in the health care sector in the County and was said to have done much to control the spread of syphilis there.

As described earlier, in the Jackson metropolitan area and, to a lesser extent in rural Humphreys County, other institutions are also in place that potentially could be mobilized to reach those thought to be at greatest risk, at least to undertake proximate and intermediate measures. Institutions are in place in the Jackson metropolitan area, for example, that already do or could potentially provide health promotion services at a more encompassing level to those at highest risk for syphilis infection services such as primary health care, health education, risk reduction, substance abuse treatment, domestic violence intervention, and other prevention services. The only institutions in the rural area that deal with health promotion are within the public health sector. The District Health Department, is the only institution with a broad enough reach in the area to bring these institutions, as well as churches and public schools, under the auspices of health education.

Schools. The public school system is acknowledged in both the urban and rural areas as the logical institution through which to reach children with health promotion messages at a formative age. However, school administrators are reported to have resisted efforts to incorporate all but the most oblique references to human sexuality and sexual health into health education curricula.

Schools in both the urban and rural areas seem to have a lack of programs to address sexually transmitted diseases, although they invite outside organizations to come in and conduct health fairs, workshops, and presentations addressing health issues. Prevention of sexually transmitted diseases and teen pregnancy can be introduced in these settings. People with whom we talked in both the urban and rural locations told us that more reproductive health education needs to be done in the schools, and at ever younger ages because of how early young people are becoming sexually active.

Religious institutions. Churches are identified as important community institutions that are in a position to reach most area residents in both urban and rural areas. Yet it is the exception and not the general rule that a local minister has sought to incorporate health education and issues of human sexuality into his/her church's community service or educational programs.

D2.2.3 What are the barriers or facilitators to reaching those at greatest risk

Although many of the necessary institutional resources may be in place or available to be mobilized, several barriers were identified that must be overcome to reach those at greatest risk of syphilis infection more effectively and to prevent others from increasing their risk of infection.

Local norms about public discourse on sexuality and sexual health. Local norms about sexuality included: (1) resistance to public discussion of sexuality and (2) the slowness of change.

Resistance to public discussion of sexuality. Public discussion in Mississippi about something as private as human sexuality is enormously complicated. Church, government, schools, race, health care, family, television, movies, music it is much easier to separate these institutional domains on paper than it is in real life. In real life, a persons relationships are embedded in several different domains simultaneously, and it is entirely possible for widely disparate values to prevail in these several domains. We heard about the dominant authority of the local churches, whose resistance to publicly discussing issues of sexuality has been coupled with an unwillingness to acknowledge a disparity between official church teachings and some congregants' sexual behaviors. The churches' resistance is mutually reinforced in the secular arena and has translated to banning broadcasts of popular network television shows, screening out candidates for elected office whose views are less resistant, and restricting the content of public school health education curricula.

Slowness of change. Changes in prevailing local perspectives about how to discuss sexual issues appropriately in public will not come quickly, nor will they come independently from changes in economic conditions or the local political ecology. We were struck by the creativity with which local health educators have approached even the most reluctant authorities, relying frequently on the strength of personal relationships to persuade pastors, organization boards, school officials, and the like to reconsider an inflexible resistance to more open and frank discussion of sexual issues. Some greater flexibility has been introduced when issues are placed in a more encompassing context; especially when sexual relationships are considered in the broader context of social relationships and personal growth and development, when the legitimacy of abstinence-based messages for teens is acknowledged, and when issues of sexual health are considered in the broader context of health promotion. Health educators and outreach workers frequently remarked that they were discouraged by the difficulties and limitations they encountered in approaching authorities. Just as frequently, however, they also acknowledge that their target audiences are far more receptive than the gatekeepers who seek to shape and limit the public treatment of sexual issues.

Local priorities. Local priorities that affected syphilis programs included: (1) the predominance of treatment and control over prevention and (2) the low priority of minority health.

Predominance of treatment and control over prevention. Treatment and control of syphilis infections are seen as important near-term health care priorities. This is understandable, given that MSDH is struggling to meet its own 1995 State Health Plan performance standards as presented in the Sexually Transmitted Disease subsection of its Preventive Services planning objectives (Mississippi State Department of Health 1995: IV-34-36).

The current investment portfolio has a heavy emphasis on treatment, however, at the expense of prevention initiatives and longer term organizational development issues. Nearly all of the MSDH priorities focus on DIS clinic staffing and productivity. It is revealing that the one prevention objective mentioned for FY1995 To continue working with the State Board of Education to establish STD/AIDS education and risk reduction as a part of a comprehensive school education bears no mention in the following section gauging the Departments progress toward meeting its planning objectives. It is equally revealing that although the MSDH 1994 Annual Report noted that the Governor signed into law H.B. 1019 (authorizing MSDH to plan for the implementation of a Comprehensive Health Education Program for grades K-12), no specific performance objectives are included in the following years plan.

Low priority of minority health. Moreover, there appears to be a disconnect between the MSDH recommendations for approaches to improving the status of minority health and the specific objectives aimed at STD treatment, prevention and control. The State Health Plan acknowledges that:

• the health care system has evolved with little or no awareness of cultural differences and with little or no direct involvement from the minority community. Therefore, any mechanism developed must incorporate these five areas:
  • Intervention plans must come from knowledge and consideration of the minority community.
  • Multiple channels of influence must be used to bring about changes in health behavior, such as involvement of the community and the appropriate health care providers.
  • Intervention efforts should be incorporated/merged into existing social structures, practice patterns of service providers, and educational channels.
  • Minority community participation should be encouraged at the earliest stages of planning and implementation.
  • Improvements must be made to make health services more accessible to minorities. (MSDH 1995: II-22)

However, nowhere in this same document can one find any performance measures to be used in gauging the development of interventions targeting an at-risk population that is disproportionately African American.

Barriers to access and utilization. Some of the barriers to reaching those at greatest risk of syphilis infection involve access and utilization obstacles, such as (1) staffing limitations, (2) transportation and hours issues, (3) cost issues, (4) facilities issues, (5) community awareness, (6) funding restrictions, and (7) issues of mistrust.

Staffing limitations. A shortage of physicians, especially in rural areas, places heavier demands on other clinic staff. Yet professional standards may restrict services that other health care professionals (e.g., nurses) can provide.

Transportation and clinic hours. We were told of plans to close one MSDH clinic located near Battlefield Park in Jackson, a neighborhood known as a locale for high-risk activities. For some people, especially in rural areas, lack of transportation is a barrier to seeking health care. Operating hours at public clinic sites do not easily accommodate working peoples schedules. For women especially, finding child care is an obstacle to be overcome.

Cost of services. For some patients, we were told that the cost of services is a subtle barrier. A chlamydia test costs $35, which is high, especially for teenagers. A visit to the new Ellis Avenue Clinic costs $10, which itself is a barrier to some potential patients. It is possible to have the clinic waive the fee, or defer payment, but one observer suggested that this is still a barrier to treatment, since the waiver must be negotiated, and many people for whom the cost is an issue are unwilling to subject themselves to the embarrassment of arguing over $10, what most people would see as a modest sum. In addition, a deferred payment means that the patient owes $20 the next time, which begins to accumulate into a significant sum.

Limited facilities for residential drug treatment. We were also told of limited facilities for residential drug treatment; most people are admitted to outpatient treatment before arriving at a residential treatment center. If they are to break the cycle of addiction and exchanging sex for drugs, they need an effective treatment and after-care program. The supply of facilities for women is even more restricted than for men, as there are often issues about child care for women during residential treatment. Because of difficulties with transportation, outpatient treatment is not a practical consideration for residents of the rural areas. For rural area residents accepted into a residential treatment program in Jackson or Greenville, access to after-care programs is especially difficult.

Lack of awareness of available services. Some categories of at-risk individuals may simply be unaware of services offered. A 1993 survey by the Mississippi Department of Education, Youth At Risk, indicated that fully 75 percent of all teens surveyed did not know how to access health services. They didn't know where to go for an exam, nor did they know where to obtain condoms, family planning advice, or free testing for HIV/STDs (Mississippi Department of Education, 1993).

Restrictions on programmatic funding. Programmatic definition of funding restrictions creates barriers to utilization of services in a number of ways. First, the same patient must schedule multiple appointments, often serially, to see different clinics for different types of service. Second, doubts were reported about the utilization of the new Ellis Avenue Clinic, a facility dedicated to STD/HIV treatment. Qualitatively, a dedicated STD treatment center is seen by some as no different from the Health Departments treatment days, which are known to put people off who worry that their health status will become publicly known.

Issues of mistrust. In the rural area, one particular barrier to STD care is the perception of a lack of confidentiality at the Health Department. In the small towns, where most people know each other, patients with syphilis are embarrassed to seek treatment because clinic employees are neighbors, friends, and relatives. There is also the fear that people seeking other services, such as WIC, will see them in the waiting room and know why they are there, and possibly make this information known around town.

This is consistent with a more encompassing feeling of distrust among African-Americans about the Health Department. Several observers suggested that MSDH is perceived by blacks as a mainly white institution. Most key leadership positions within the Department are occupied by whites. Only one of nine district health officers throughout the state is African American. People within the Health Department acknowledge their awareness of this perception. In addition to recognizing that most management positions are held by whites, Health Department officials also acknowledge that the Department does not have a good reputation for treating patients respectfully. Although no one outside the Health Department mentioned Tuskegee to us, several Health Department staff suggested that part of the mistrust of the Health Department in the context of STD treatment and control is attributable to some general awareness of the Tuskegee legacy.

Adequacy of public health staff recruitment and training. Barriers related to staffing included: (1) staff attitudes and (2) clinic procedures.

Clinic staff attitudes. While the MSDH may not be able to control its association with the legacy of Tuskegee, there are near-term barriers to access and utilization that appear to be addressable through organizational development efforts. For example, clinic staff attitudes and the waiting-room environment are said by some to discourage people from seeking testing and treatment. Clinic staff members are mostly white, while most patients are African American. Many patients report feeling they are treated with disdain. Moreover, it is difficult to separate concerns about race-based attitudes from concerns about the stigma associated with STDs. We were told that in many instances, clinic staff display a negative attitude towards people who come in with STDs. It occurs to us that staff training can address some customer satisfaction issues, along with some of the concerns expressed about confidentiality in testing, especially in the rural clinics.

Clinic procedures. We were told about a glass window syndrome, referring to the typical clinic waiting-room setup, where patients must announce their names to a receptionist in a raised voice and through a glass window, and subsequently are called by name when they can be seen. We were also told of instances where nurses do not follow standing orders for syphilis treatment and of instances in which female nurses were not comfortable conducting urogenital tract exams with male patients.

D2.3 Innovative Strategies

It must be recognized that key decisions are made at the local level about where to locate and how to operate clinics, public transportation, parks and recreation programs, law enforcement authorities, and public schools. If county commissions, city councils, school district boards, and public health advisory boards are to target high-risk neighborhoods with long-term community development investments, it will be because a coherent, persuasive investment strategy has been presented with a unified voice that speaks for neighborhood groups and community-based organizations. Clearly, grass-roots organizing around health and social issues relating to syphilis prevention and control is in progress and can be built upon.

In addition to outreach activities undertaken by comprehensive Jackson/Hinds Comprehensive Health Center and the Health Department, youth service organizations like Operation Shoestring, the Children's Home Society, and Boys and Girls Clubs are also involved in age-appropriate health education activities that include discussions of sexuality and sexual health. The American Red Cross Chapter has been a source of HIV prevention training, and the Community Health Program at Jackson State University has been a source of numerous health education activities. Other social service programs that target many of the same persons at risk for syphilis infection in the Jackson metropolitan area include drug treatment centers like the New Hope Foundation and Harbor House, Jackson State University's National Alumni AIDS Prevention Project, and local colleges' fraternity/sorority mentoring activities.

In Humphreys County, formally organized institutions include the Family Service Training Center in Belzoni, which offers services such as job skills and GED training, nutrition education, child care and other services. Also, a charitable organization in Isola, Helping Hand, distributes food, clothing, and disaster relief to needy people.

However, many challenges to this type of organizing exist. Below we discuss these challenges, first in the urban, then in the rural setting.

Challenges of organizing community efforts in urban areas. City- and county-wide coalitions need grassroots organizations as their basic building blocks. In Jackson, our brief site visit leaves us with an uneven impression about the effectiveness of neighborhood organizing. A small cadre of energetic, resourceful, and dedicated activists maintains an informal institutional alliance that covers many important bases. The daily grind of coping with inner-city poverty dissipates energy, however, and distracts from neighborhood organizing. Due to at least two decades of white flight, the city is filled with pockets of shotgun houses in dilapidated condition mostly owned by absentee landlords and occupied by poor tenants who are reluctant to complain out of fear that they will be evicted and unable to find affordable housing alternatives. In short, for many of the city's neediest areas, no neighborhood exists to link with counterparts and divert public investment resources towards efforts through which they could make a significant difference. A neighborhood cannot be created solely by outsiders, but the conditions under which neighborhoods can grow and flourish can be promoted by outside assistance.

Challenges of organizing community efforts in rural areas. Small towns in Humphreys County are widely dispersed in a large agricultural area, and it may be difficult to create any county-wide coalition. Efforts to address concerns most likely need to be undertaken town by town. We encountered one example of this local-level organizing in Isola, where a community planning group has been formed by local leaders to address the needs of the residents. The group has been collaborating with the District III Health Officer, members of MSDH, and a representative of the Community Health Advisory Network from Jackson. The group is exploring ways to purchase two adjoining properties in Isola to build a community center. The community center would be used to provide GED and job training, recreation, exercise, day care, as well as health education. The members of the community group are looking for ways to involve Country Skillet, a local employer, in their efforts to build and operate the community center and are investigating the possibilities of receiving rural empowerment community grant funds.

Appendix D3 - Case Study of Richland and Orangeburg Counties, South Carolina

D3.1 Community Profiles

The two South Carolina sites were Richland County (urban) and Orangeburg County (rural).

D3.1.1 Richland County (Columbia) Urban

Geographic Characteristics

Columbia is South Carolina's state capital, and the center for finance and education in this growing state. The Columbia Metropolitan Statistical Area, consisting of Richland and Lexington counties, is the third largest metropolitan area in the state, with a 1990 population of 453,331. The manufacturing center of Greenville-Spartanburg in the northern part of the state (830,563), and the coastal tourist and defense center of Charleston (506,875) are both larger and have each grown at faster rates than Columbia since 1980 (US Bureau of the Census 1994a).

Demographic Characteristics

The Columbia metropolitan area grew by about 11 percent between 1980 and 1990, with most of this growth concentrated in suburban areas of Lexington County. The City of Columbia itself is located in Richland County, with a 1990 population of 103,473. The metropolitan area was about 30 percent African American and 68 percent white in 1990; Lexington County is about 88 percent white and 11 percent African American, while Richland County is 42 percent African American and 56 percent white. The white population of Richland County decreased slightly between 1980 and 1990, while the black population increased by 15 percent. Hispanics in the metropolitan area represent less than 1 percent of the population, but this groups representation in the area population is increasing relatively rapidly.

Economic Characteristics

Per capita income in metropolitan Columbia was $16,152 in 1990, with 13.2 percent of the areas population falling below the poverty level. However, a marked income disparity can be seen between African Americans and whites in the area; per capita income for African Americans was $8,259 in 1990, or roughly half that of the areas white residents. Significantly, only 7 percent of the areas white residents live in households with incomes below the poverty level, while 30 percent of the areas African-American residents were below the household poverty level. More than 47 percent of all African-American children under the age of five years live in households with incomes below the poverty level.

Employment in the metropolitan Columbia area is concentrated in the government (27 percent), trade (22 percent), and services (21 percent) sectors; in addition to the state government and the University of South Carolina, the US Army has a significant installation on the edge of town at Fort Jackson.

Social Characteristics

Columbia was established at the beginning of the 19th century as the compromise government seat, closer to upland residents of the state than the thriving Charleston port district. Although centrally located in the state, Columbia is less of a commercial and industrial center than are the Charleston and Greenville/Spartanburg areas. And although Columbia has not escaped the epidemic of crack cocaine use that has swept through metropolitan areas throughout the US since the mid-1980s, the two larger metropolitan areas in the state are thought to have a larger and more persistent set of drug-related problems than Columbia.

The Columbia metropolitan area is divided into 8 public school districts, and another 40 private elementary and high schools operate in Richland and Lexington counties. Post-secondary institutions include the University of South Carolina, Midlands Technical College, and several private colleges: Columbia College, Allen College, and Benedict College.

The State Legislature enacted comprehensive health education legislation in 1994, but implementation authority is left to each individual school district. Great variability is reported in the approaches used by individual districts in addressing topics of human sexuality, sexual health, and STD prevention.

The church is seen as a powerful institution throughout the state of South Carolina, but there is little evidence of its involvement in raising public awareness about effective approaches to controlling substance abuse or the spread of sexually transmitted diseases. Conservative Bible Belt standards appear to prevent churches from directly addressing these controversial issues, or from separating issues of morality from matters of public health.

Other organizations in Columbia are directing efforts towards substance abuse and disease prevention and control. Some of these include the American Red Cross, the Lexington-Richland Alcohol and Drug Abuse Council, the South Carolina African American HIV/AIDS Council (itself a coalition of community-based organizations), the community-based AIDS-Busters, the Columbia Housing Authority, the University of South Carolinas School of Public Health, and various youth recreation organizations.

Health Care

Health care for low-income residents. In the Columbia metropolitan area, health care is available to low-income residents mainly through the Public Health Department, a subdivision of the State Department of Health and Environmental Control, and through Richland Primary Health Care, a not-for-profit care provider with two clinics in Richland County. The Public Health Department operates several clinics in the four-county Palmetto District, including STD clinics at its offices in Columbia and Lexington County. The Columbia STD clinic saw about 500 patients per month in 1995, while the Lexington clinic averaged about 100 patients per month. Six Disease Intervention Specialists serve the four-county district. The Richland County STD Clinic is participating in the CDC-sponsored Syphilis in the South project.

Richland Primary Health Care's clientele is drawn primarily from the indigent and homeless population of metropolitan Columbia and nearby Eastover. While the Eastover clinic has been in operation for 10 years, the central city clinic location was opened in March 1995. Planned Parenthood of South Carolina operates a clinic in Columbia, offering a full range of reproductive health services, including STD testing. Planned Parenthood's clientele is drawn mainly from college students and young adults who do not have health care insurance through their work.

Other health care facilities. The federal Department of Veterans Affairs operates a medical center near Fort Jackson on the eastern edge of Columbia. The VA center has a dedicated patient population (military veterans and their eligible dependents) that, although somewhat older, includes some HIV+ and syphilis-infected persons. Emergency room care is available from two private hospitals (Columbia Memorial and Baptist).

The South Carolina Department of Corrections operates a large complex in Lexington County that includes reception and evaluation facilities for men and women. Medical screening and, when necessary, treatment is provided to all inmates upon sentencing and entry into the state prison system.

D3.1.2 Orangeburg County Rural

Geographic and Demographic Characteristics

The City of Orangeburg is the county seat and also, with its 14,000 residents, the largest population center in Orangeburg County (total population of 87,000 in 1994). Located between Columbia and Charleston, the county is largely rural in character, but growing at a modest rate of less than 1 percent annually. The county population is about 58 percent African American and 41 percent white, with the black portion of the population increasing slightly (from 56 percent) since the 1980 census.

Economic Characteristics

Despite the areas rural character, employment in the county is dominated by manufacturing (farm and automotive equipment, chemicals, and clothing), government, and education (including South Carolina State University and a number of private colleges). Per capita income for county residents was $9,004 in 1990, although per capita income for whites was $13,273, compared to $5,965 for blacks. About 10 percent of the county's white residents belonged to households with incomes below the poverty level, while more than 36 percent of the county's black residents were below the poverty level. Forty-four percent of the county's black children under 5 years of age were below the poverty level.

Social Characteristics

Drugs have been regarded as a serious problem in Orangeburg. In 1994, the governor called the National Guard to an area near the South Carolina State University campus known as The Hill to tear down several crack houses.

Orangeburg County has eight public school districts and another 12 private schools. Post-secondary institutions include South Carolina State University, Claflin College, Southern Methodist College, and the two-year Orangeburg-Calhoun Technical College.

At Orangeburgs Wilkinson High School, the Family Health Center established a student health service center in November 1995. The main reason cited for creating the school-based center was a lack of public transportation that students could use to reach other facilities. The school-based center provides diagnosis and treatment for acute and chronic illnesses, comprehensive physical exams, immunizations, family planning, counseling, health education, and free pregnancy tests. The school district does not permit the student health center to distribute condoms.

Other organizations in Orangeburg County, mainly located in the city of Orangeburg but also distributed throughout the area, are directing efforts towards substance abuse and disease prevention and control. Some of these include the Orangeburg-Calhoun-Allendale-Bamberg (OCAB) Community Action Agency and the Minority AIDS Council (itself a coalition of numerous community-based organizations and local government agencies).

Health Care

In Orangeburg County, the Family Health Center (FHC) clinics are a main source of primary health care, along with the Orangeburg/Edisto District Health Department clinics and physicians in private practice. Acute care is provided to Orangeburg County residents by the Regional Medical Center of Orangeburg and Calhoun counties. In addition to its main offices in Orangeburg, the Family Health Center also operates seven satellite clinics throughout the county. FHC has a health educator and three social workers and provides services in collaboration with the Brooks Health Center at South Carolina State University and the Changes Clinic at the Health Department. FHC also operates a mobile unit, staffed by a physician or nurse practitioner, which is available for Orangeburg, Calhoun, and Bamberg counties. The Public Health District operates a clinic in Orangeburg and three satellite clinics throughout the county. The Regional Medical Center was originally a small private hospital that is now a 286-bed acute care facility owned by Orangeburg and Calhoun counties and serving a six-county area.

D3.2 Key Assessment Issues

D3.2.1 Who is at greatest risk of acquiring/transmitting syphilis

The factors thought to contribute to heightened risk of syphilis infection are somewhat different in urban and rural areas. Early syphilis morbidity has declined steadily in South Carolina since 1990. In early 1996, the greatest number of cases are concentrated among residents of the urban areas (Greenville/Spartanburg, Columbia, and Charleston). Two years earlier (when the Syphilis in the South grant application was prepared and when case selection criteria for this project were under consideration), Orangeburg County was among the problem areas in the state, but morbidity has declined substantially since then. State and local health officials attribute this decline to stepped-up control activities focusing on contact tracing and partner notification.

In addition, views concerning risk factors are influenced by how clearly respondents distinguish between syphilis and other sexually transmitted diseases and by their confidence in the reporting system. Few respondents used the term core transmitter."

Syphilis versus other STDs. Syphilis is not the most prevalent sexually transmitted disease in either the urban or rural setting, but the risk factors associated with syphilis were more clearly distinguished from those of other STDs by the health care providers and public health agency staff among our respondents than by respondents in other categories. Representatives from community-based organizations, school districts, social service agencies, and substance abuse treatment facilities do not differentiate as precisely between syphilis and other STDs. Almost everyone to whom we spoke believes that unprotected sex and multiple sex partners increase the risk of becoming infected with an STD, but those respondents who do not specialize in health care glossed over differences between exposure to syphilis, gonorrhea, chlamydia, and, in recent years, even HIV.

Confidence in the reporting system. Reported cases of early syphilis, in both the urban and rural South Carolina settings, almost exclusively involve low-income African Americans. Yet disagreements were voiced about the reliability of the reporting system. Some public health agency staff and community activists feel that morbidity statistics reflect some bias, because they believe that many white residents turn to private physicians for treatment, rather than to public health clinics. Although private physicians are required to report a syphilis diagnosis, they are suspected of providing an official diagnosis of a more general nature, treating their patients without laboratory tests, and thereby getting around reporting requirements. We also heard the belief expressed, however, that private physicians are ever mindful of the potential for litigation. From this perspective, physicians are more likely to order blood tests if syphilis in particular is suspected, to protect themselves from malpractice accusations. It may be that gonorrhea and other STDs go under-reported among private physicians, but once blood is drawn for syphilis testing, a positive result makes it into the reporting system.

Core transmitter concept. Almost everyone we interviewed could identify categories or groups of individuals whom they felt to be at high risk for transmitting syphilis, but practically no one uses the terms core transmitter or core transmitter group to describe them. South Carolina is taking part in CDCs Syphilis in the South epidemiology program, and the term core transmitter was used in the original program application. Because of the efforts made to consult with a wide range of allied and collaborating organizations while preparing the application, the term is not unfamiliar. More commonly used today is the term high-frequency transmitter, which seems to fit the epidemiological evidence showing a readily identifiable group of people whose behavior is able to keep the disease reproduction rate above 1.0. People who are high-frequency transmitters are thought to live relatively close to one another in urban areas, but this is not necessarily true in rural areas.

Below we first discuss several risk factors that seemed common to both the urban and rural settings, and then discuss additional risk factors identified separately for the two South Carolina sites.

Substance abuse. Local officials gave us mixed impressions about recent patterns in drug use, especially crack cocaine. A recent sample of newly reported syphilis cases indicated that 30 percent of the infected individuals were involved in substance abuse. Public health officials point out, however, that the use of crack cocaine has decreased over the last three years. We are two years past the height of the epidemic. There are not as many crack houses in the rural areas as before. We see a fair amount of crack use in employed people. The use of crack cocaine has decreased because drugs are no longer in fashion. Heroin is coming in and may be much less likely to stimulate risky sexual behavior.

Age. In both the urban and rural locales, people noted with alarm the early ages at which teens are initiating sexual activity and that a substantial proportion of area teens have multiple partners and unprotected sex. While syphilis infections among adolescents are acknowledged to be rare, gonorrhea and chlamydia are more prevalent. As one health care professional told us, unless behaviors change, as these teens grow older their risk of syphilis infection is expected to increase.

Richland County/Palmetto Health District Urban

Several risk scenarios were sketched by respondents in the urban site interviews, depending on the category of respondent:

Those who provide services to homeless and indigent residents in the city identify people in these circumstances as having an increased risk for syphilis infection, particularly women who may circulate with their children among several temporary living situations to keep off the streets and out of the shelters.

Corrections facility staff told us that inmates in corrections institutions receive an initial screening (and treatment if necessary) upon entry to the prison, but male inmates may become infected through sex with other inmates and then infect their long-term partners on the outside upon release or during surreptitious conjugal visits.

Community activists told us that young adults, especially women in their 30s, may be engaged in a series of relationships involving unprotected sex and therefore more likely to be exposed to STDs, including syphilis.

DIS staff reported that drug users (especially users of crack cocaine), who exchange sex for drugs or for money to buy drugs, continue to expose themselves to risk of STD infection. DIS staff appear to be quite familiar with the places where these activities occur.

The public STD clinic in Richland County reports treating very few individuals for repeated syphilis infections.

Men having sex with men are at risk, especially anonymous sex at highway rest stops. One respondent also mentioned that bisexual activities among military men are probably under-reported and that this leads to elevated risk for STD infections, including syphilis. It was reported to us that in the late 1970s and 1980s, syphilis was largely an infection seen in gay and bisexual men. The gender ratio was said to be three infected males to every infected female. Now, it is reported, the ratio has shifted closer to 1:1.

HIV co-infection. Some overlap is seen among those at greatest risk for syphilis and those at greatest risk for HIV infection, but these are not identical risk categories. Current rates of co-infection are said to be rather low, in the 1 to 2 percent range. The prediction is, however, that having a syphilis infection increases the chances of becoming infected with HIV, and the same risky behaviors that increase the chances of HIV infection also increase the chances of becoming infected with syphilis.

Orangeburg County/Edisto Health District Rural

Race and socioeconomic status. Lower income African Americans are seen as having a greater risk of syphilis infection than their white counterparts, but syphilis is also showing up among black residents in higher socioeconomic strata. DIS staff believe that professionally employed persons with multiple sex partners are responsible for a significant number of recent syphilis cases.

Age. Health and social services providers expressed considerable dismay about the early ages at which teens initiate sexual activity and about the fact that it is unprotected sex with multiple partners. Teens are more likely to become infected with gonorrhea, chlamydia, or trichomoniasis, however, while those infected with syphilis are generally older. Similarly, at South Carolina State University, students present with STDs, but almost never with syphilis.

Substance abuse and repeat infections. The connection between crack cocaine use and syphilis is not as strong now as it has been in recent years. The relatively small number of people treated for repeat syphilis infections, however, are often crack users. Those treated for repeat infections are generally women.

D3.2.2 What institutions are thought to be most likely to reach those at greatest risk

South Carolina's principal public health agency is the Department of Health and Environmental Control (DHEC). In addition to Health Services, this department's authority covers Oceans and Coastal Protection, and Environmental Quality Control. The Health Services Division administers programs in each of the state's 46 county health departments, which are organized into 13 health districts. Each District Health Officer is responsible for the county offices and clinics within the District, the operations of the Disease Intervention Specialists, and all district-level administrative and programmatic operations.

Within the statewide offices of DHEC's Health Services administration, Venereal Disease Control (HIV/AIDS/STD Prevention) is organized as a single programmatic function. In a January 1996 Draft of the Health Services Long Range Plan: 1996-2000, HIV/AIDS/STD prevention is listed among the very highest priority programs for the Governor's 1996-97 budget, outranked only by family planning and tuberculosis control programs.

In both the Columbia metropolitan area and rural Orangeburg County, it appears to us that other institutions are also in place that could be mobilized to undertake proximate and intermediate measures to reach those thought to be at greatest risk. Below we discuss relevant institutions first in the urban and then in the rural site.

Richland County/Palmetto District Urban

Health Department. Within the Health Department, DIS staff activities are organized by geographic area and institutional domain. For example, one staff member works with the areas Department of Mental Health facilities and the west side of Columbia. Another works with the military base and several housing projects. Another works with prison facilities and the congenital syphilis cases that appear in metropolitan area hospitals, while another works with the portions of the Palmetto District outside of Richland County. This organization of staff assignments facilitates the development of long-term relationships with cooperating institutions.

Other health care providers move to integrated services. Between the Health Department, Richland Primary Health Care, private physicians, the Department of Veterans Affairs, and Planned Parenthood, primary health care services are available in Columbia. Richland Primary Health Care is new to Columbia in the last year. The Health Department operates one STD clinic in Richland County, which is open Monday-Friday, 8:30 am - 4:00 pm. Nearby Lexington County has a general clinic that offers multiple services, including STD testing and treatment. To be more responsive to patient needs, Health Department officials are examining ways of integrating programs like Family Planning, Maternal Health, Adult Immunizations, and STDs. The Department is also considering establishing alternative sites in conjunction with drug treatment and public housing facilities.

Integration of programs has the promise of a more patient-centered approach to service delivery, but poses some organizational development challenges for DHEC, particularly in cross-training health care professionals who may resist becoming involved in STD treatment. The Palmetto Health District operates a training center available to Health Department personnel from throughout the state. What had formerly been a four-day training session is being revamped into a two-week session. The new format had not yet been implemented in March 1996, so it is difficult to tell whether the training session's increased length will deter some prospective trainees from taking that much time away from their regular responsibilities.

We were told that the move to integrated family support services will also involve a shift in service delivery responsibilities among health care providers. Under one proposed scheme, Level 1 service providers would prepare a service needs assessment and plan of care, while Level 2 providers would follow this plan of care with the assistance of Level 3 providers (paraprofessionals and community health assistants). While funding is available to support additional training for primary care assistants, special attention may be needed for staff who have not previously dealt with STD patients on a regular basis. We were told that STD clinic nurses and assistants know what they are getting into when they seek a job at the clinic; they do not appear to have professional problems conducting physical exams or taking sexual histories. Staff with more general training, however, do resist sometimes. The move toward cross-training nurses and nursing assistants may require trainers to pay special attention to those who are adding STD treatment and counseling to their skill set.

Drug treatment centers. The Syphilis in the South program has sought an agreement to have screening operations established in at least one drug treatment center (Lexington-Richland Alcohol and Drug Abuse Council, or LRADAC) and is also pursuing similar agreements in state and local correctional facilities (see section on Correctional Facilities below).

Schools. South Carolina's Comprehensive Health Education law offers guidance about age-appropriate instruction in public schools regarding sexuality and reproductive health, but gives local school districts the responsibility for implementing these guidelines. School districts vary considerably in how classroom instruction is to be approached. Several health educators singled out Richland School District No. 1, for example, as one district in the city where administrators have been highly supportive. Health educators told us that their success in being involved in classroom activities depends largely on personal relationships and informal contacts with principals and teachers. Considerable political pressure is present in the state legislature to revise the current Health Education statute and insist on exclusive use of abstinence messages in any public school instruction. Overall, we are left with the impressions that:

Reaching youth through the public schools with specific information about risk reduction and available health services is spotty, and

Because of uneven implementation, it is possible that the current law will be seen as ineffective, and even this modest set of requirements will be eliminated.

Interestingly, one health educator indicated that s/he has been able to use school facilities after regular school hours to convene a teen discussion group.

Religious institutions. A few churches in Columbia have begun to use organized activities to focus on health promotion. When these activities focus on sexuality issues, it is usually HIV prevention and not syphilis that provides the main emphasis.

Correctional facilities. STD screening at the County jail facilities is planned as part of the Syphilis in the South program. DHEC already works closely with the State Corrections Department, which operates central Reception and Evaluation facilities for men and women near Columbia. After an initial screening, health education activities are available for voluntary inmate participation, and no further medical tests or examinations are conducted unless symptoms are present. One DIS staff member's assignment includes the state corrections facilities, and his work focuses both on contact tracing for the Reception and Evaluation centers and pre-release counseling for inmates who are about to complete their sentences. LRADAC, the substance abuse treatment organization, also works with inmates, providing pre-release counseling to help with the transition to the outside. Although this counseling currently focuses on drug and alcohol use, an opportunity is presented here to reinforce messages about STD risk reduction and sexual health more generally.

Housing authority. The Columbia Housing Authority is a strong advocate of co-locating social services with the community centers in each public housing project. After-school programs for teens are organized at several of the public housing community centers, and at least one of the centers (Saxon Homes) offers an on-site child immunization program to its residents. The Housing Authority's Resident Initiatives Department also sponsors health fairs through its Maternal Outreach Managed Services (MOMS) program and has a trained HIV/AIDS counselor on its staff. The potential for collaborative health education efforts involving DHEC and the Housing Authority could be exploited productively.

Community-based organizations. Columbia is also home to some energetic community activists whose creative use of informal information channels has made an important contribution to local health education efforts. While the principal focus of these efforts has been to reduce the risk of HIV infection, they have targeted audiences primarily including adolescents, college students, and adult women; the main risk reduction messages apply more generally to preventing all STDs. These community-based efforts are focused in places where people gather informally and where the talk is about relationships: hair salons, barber shops, night clubs, liquor stores. Adolescents get involved through after-school programs and church youth groups. What began as informally instituted efforts in the mid-1980s have by now been channeled into several formally organized projects that receive public and private financial assistance: the South Carolina AIDS Education Network, Shear Devotion, the Nurturing the Tree of Life project, and AIDS Busters. Among these projects formal outcome evaluations have been conducted only for the youth-oriented AIDS Busters project and show a significant change in knowledge about HIV risk reduction.

SC Minority AIDS Council. Run by representatives from the State Health Department and community-based organizations such as AIDS Education Network, Shear Devotion, and AIDS Busters, the SC Minority AIDS Council is a broad-based collaboration involving representatives from 35 different area organizations spanning health care, social service, educational, housing, and criminal justice domains. The Councils main focus is HIV prevention and services to persons with HIV/AIDS. Formed in 1988, its main financial support comes from CDC. In addition to sponsoring an annual conference, the Council provides educational workshops in parks and public housing projects.

Orangeburg County/Edisto District Rural

Health department and other health care providers. The Health Department's Edisto District is widely praised for the level of primary care services it provides. The District's DIS staff are extremely knowledgeable about the community and resourceful in focusing their contact tracing and notification activities. Improved access to services in outlying areas is being pursued by establishing a network of satellite clinics. The Family Health Center (FHC) was founded in 1976 and is the primary source of health care for low-income residents of Orgngeburg County. Services are offered on a sliding fee scale and include adult medicine, pediatric medicine, OB/GYN, dental, and urgent care facility, and a pharmacy. FHC also has a health educator and a social worker.

Services at the local hospitals, however, come in for some criticism. We were told by one local health care professional that between the County's two hospitals one is mainly elderly care, and the other is insufficient. There are no residency programs for the Universities. There are a limited number of nurse practitioners, registered nurses, and physician assistants. The hospital in Orangeburg is under management from another state.

The Changes Clinic, staffed by physicians from the Family Health Center, operates after hours at the Health Department. Its services are targeted primarily for HIV+ patients and persons with AIDS.

The Brooks Health Center operates on the campus at South Carolina State University. In 1995, the Center received about 14,000 visits, including about 500 for STDs and 800 for family planning. Physical exams are a routine part of the university's admissions procedure, including laboratory tests to confirm syphilis. A Center staff person told us that positive tests for syphilis are extremely rare, perhaps a total of two to four cases in the last 10 years.

Schools. Health education classes in the Orangeburg public schools were described for us by school nurses, primary health providers, and community organizations representatives. Students receive messages about saying No to drugs starting in kindergarten, and beginning in middle school grades, they learn about human reproductive physiology and anatomy. Students are also shown what condoms look like. One high school offers a Teens Against Premarital Pregnancy program, which emphasizes abstinence but also discusses contraception. Except for HIV, STDs do not appear to receive substantial emphasis in the health curriculum. In one local Health Department staff member's view, at the public schools, they talk about abstinence. They show them what condoms look like. They teach the reproductive physiology, but just say not to have sex. They did not get into STDs.

Religious institutions. Abstinence is also the central message in church-based discussions of sexuality involving adolescents. We were told of one local church where youth sign a card promising that they will not have sex until they are married (complete with a ceremony and ring). The youth take part in a church-sponsored course, make a vow at the altar, read a biblical passage about being pure, and are then presented with a ring by a parent.

Community-based organizations. Orangeburg-Calhoun-Allendale-Bamberg (OCAB) Community Action Agency appears to be a well-regarded participant in general health promotion activities, although syphilis is not as high a priority as teen pregnancy prevention, maternal and child welfare, and HIV prevention. The Agency sponsors a peer educator project among adolescents and young adults (ages 13 to 24) focusing on HIV/AIDS. Peer educators are trained by the American Red Cross and the AIDS Busters program based in Columbia. They canvas high-risk neighborhoods, do needle demonstrations, condom demonstrations and distribution, and can present educational information in street terms. The project enjoys the cooperation of several local churches and community centers. OCAB is also a participating organization in the SC Minority AIDS Council.

D3.2.3 What are the barriers or facilitators to reaching those at greatest risk

Although many of the necessary institutional resources may be in place or available to be mobilized, several barriers were identified that must be overcome to reach those at greatest risk of syphilis infection and prevent disease transmission more effectively.

Local norms about public discourse on sexuality and sexual health. Public discussion in South Carolina about human sexuality is enormously complicated. Church, government, schools, race, health care, family, television, movies, music it is much easier to separate these institutional domains on paper than it is in real life. In real life, a persons relationships are embedded in several different domains simultaneously, and it is entirely possible for widely disparate values to prevail in these several domains. We heard about the dominant authority of the local churches, whose resistance to publicly discussing issues of sexuality has been coupled with an unwillingness to acknowledge a disparity between official church teachings and some congregants' sexual behaviors. The churches' resistance is mutually reinforced in the secular arena and has translated to screening out candidates for elected office whose views are less resistant and restricting the content of public school health education curricula.

Local priorities. Barriers relative to local priorities include: (1) prominence of HIV/AIDS and other health care issues and (2) missed infections.

Greater prominence of HIV/AIDS. STD prevention is identified as a high priority statewide, but syphilis is given less specific attention than HIV/AIDS. In a January 1996 draft of the Health Services Long Range Plan: 1996-2000, HIV/AIDS/STD prevention is listed among the very highest priority programs for the Governor's 1996-97 budget, outranked only by family planning and tuberculosis control programs. HIV/AIDS prevention has received more public attention in recent years than other STDs. Furthermore, from the perspective of the Health Department's DIS staff, handling HIV contacts along with syphilis is difficult, since HIV contact tracing is more labor intensive (you have a longer period and many more contacts with HIV), taking time away from other work.

Greater prominence of other health care issues. In Orangeburg County, the rate of HIV infection is on the rise, but STD prevention and treatment take a back seat to other health care needs. Prenatal and neonatal care are seen as more pressing problems. Cardiovascular disease, teen pregnancy, diabetes, and cancer are problems identified especially within the African-American community. Also, we heard from one community activist that the health effects from industrial contamination should rate a higher priority. However, the jobs associated with industrial activity make it difficult to talk openly about environmental concerns without engendering controversy.

Missed infections. In Richland County, the STD clinic deals with resource limitations by setting treatment guidelines based on symptoms or a patient's sexual history. Clinic nursing staff feel that some unspecified number of infections are missed because the patients are asymptomatic when they come to the clinic, or because their histories are incomplete or inaccurate.

Barriers to access and utilization. Barriers to access and utilization include: (1) location issues, (2) inadequate staffing, (3) the issue of mistrust, and (4) restrictions on Medicaid patients.

Location issues. We heard many observations about the inaccessibility of primary care and STD treatment services in areas of Richland and Orangeburg Counties where public transportation service is poor or altogether absent. Health Department officials are certainly aware of the tradeoffs over cost efficiencies of centralized facilities and the improved accessibility afforded by a more decentralized approach. Even beyond the capital costs for satellite clinics, staff productivity is lowered, because, as one person explained:

When you out-station people in that many locations you have to be able to provide a full array of services. By doing that, you may not have the traffic on any given day to fully utilize the staff. So what happens quite often is that you have your staff in one area two days a week, another area three days a week; or one area in the morning and another in the afternoon. By doing that, you are moving your people around so much that you lose something in the process. Central Office comes in and counts the number of (staff) and the number of (patients served), and the ratio is on the high side. The reality is that the (staff) are providing services in so many locations that they are losing significant time in traveling. People who receive services are delighted, but the actual cases we are able to process may not be the same as it would be if all the staff were located in one large clinic.

Inadequate staffing levels. Access issues appear to receive consistent attention from the Health Department, although limited staff resources sometimes result in STD clinic patients being asked to return another day. DIS staff cutbacks have resulted in reduced outreach efforts: We used to go out to health fairs, do screenings at housing projects; we used to interview every case of gonorrhea and PPNG [Penicillinase-producing Neisseria gonorrhoea], but simply lack the staff to undertake these sorts of efforts any longer. We were also told that disease treatment and control is not solely the DIS responsibility. Many others are involved clerical staff, social work staff, clinical nurses and in each of these functional areas, staffing levels are felt to be barely adequate.

The issue of mistrust. Use of the STD Clinic in general, especially by African Americans, may be somewhat lower because of mistrust. How much lower is difficult to quantify, but we heard from Health Department staff and from community organization representatives that the Department does not help itself when it treats patients insensitively. This is complicated, of course, since even a well-intentioned staff member can inadvertently be regarded as off-putting by a patient. In one observer's words:

It is an embarrassing thing to come in for STD treatment. People are very sensitive to the manner in which they are treated. Some staff are rude. Some are not friendly. Often, staff don't intend to be, but because of the sensitive nature of having an STD, it is perceived differently by the patient. But I have also seen staff behave inappropriately, (making) statements like, You're back!

Health Department staff feel that the legacy of Tuskegee is lurking in the background of this trust issue. That is, not very many people in the African-American community necessarily know in detail what happened with the Tuskegee study, but the name is a reminder of the long line of injustices that have been visited upon black people, a symbol that the public health authorities are out to get blacks, they (the public health authorities) are not to be trusted.

Restrictions by private providers on number of Medicaid patients seen. If utilization of the Health Department primary care and STD treatment services is significantly lower because of trust issues among African Americans, a substantial number of low-income persons may be going without health care of any sort. We were told consistently that private physicians often restrict the number of Medicaid patients they will see. One can speculate that low-income patients who are not seen by private physicians, and who stay away from the public health care providers because trust is lacking, may be among those at elevated risk for syphilis infection.

Public health staff recruitment and training. Barriers related to staffing include: (1) competition with the private sector and (2) lack of cultural diversity.

Competition with the private sector. The public health care sector has a difficult time competing for trained staff in South Carolina because better pay and working conditions are often available in the private sector. Recruitment difficulties can result in barriers to service, as positions remain vacant. For example, we were told by one Health Department staff member:

We did a turnaround survey two years ago and found that we had a problem with access to clinical care, a lot of patients were being turned away that day, or not being seen within the next two days. Since then, we have tried to make it easier to see patients. We did another turnaround survey last March (1995), and it had improved significantly. We know we still have a problem with turnaways, because there are not enough nurses. In some areas we are doing fine, but in other areas there is not enough nursing staff. It is really hard to get nurses.

Lack of cultural diversity. In addition, the staff who are recruited may not be matched to the patient population in a way that overcomes trust and confidence barriers. In the Palmetto District, we were told that the nursing staff is 99 percent white and includes only one male nurse. African-American staff say they receive many more requests than they can honor from black females who say they would prefer to talk to someone more like themselves.

At the state level, DHEC has recognized and placed a high priority on both cultural competence training and recruitment, retention, and promotion of minority staff. We were told by one central office DHEC staff member that achieving a culturally competent organization depends not just on training, but on support from the top levels of management, which appears to be happening in the form of long-range planning goals.

Difficulty of sustaining community organizing and coalition-building. Informal and formally instituted collaborations are in place in both Richland and Orangeburg counties, joining together organizations and agencies from health care, educational, church, housing, and criminal justice/law enforcement domains. The presence of these collaborative efforts is evidence that consensus can be built about issues that are important to the community; syphilis has not been an explicit focus of organizing activities, but HIV/AIDS and teen pregnancy prevention have been.

The major barrier to sustaining these collaborations appears to be programmatic restrictions on how funds can be spent. Funding sources often place limits on how funds can be spent in the interests of increasing accountability and avoiding duplication of services. These limits, however, make it difficult for organizations and agencies with different funding sources to find enough common ground to work together. Limits placed on the ways in which monies can be spent may result in organizations having different staffing patterns (levels and areas of expertise), serving different geographic areas, answering to different sorts of boards or advisory panels, and having different administrative structures in place to account for their activities.

D3.3 Innovative Strategies

In both Richland and Orangeburg counties, we were told of innovative programs that address social and health issues, some including STDs. Although not many of the programs specifically address syphilis, these programs are worthy of mention, both because of the work they are doing and because they could be effective conduits for further interventions relating to syphilis and other STDs. Italics highlight multiple foci below.

Programs through government agencies.

The Columbia Housing Authority is a strong advocate of co-locating social services with the community centers in each public housing project. After-school programs for teens are organized at several of the public housing community centers, and at least one of the centers (Saxon Homes) offers an on-site child immunization program to its residents. The Housing Authority's Resident Initiatives Department also sponsors health fairs through its Maternal Outreach Managed Services (MOMS) program, and has a trained HIV/AIDS counselor on its staff.

The Central Offices of DHEC are engaged in cultural competency training for staff statewide, aiming to increase staff awareness of the diverse perspectives that staff and clients bring to service and care settings.

Programs through youth-serving organizations.

Orangeburg Teens Against Premarital Pregnancy is a high school-based program that involves adolescents in discussions of both abstinence and contraception methods.

Programs through other CBOs.

South Carolina Minority AIDS Council is a broad-based collaboration involving representatives from 35 different area organizations spanning health care, social service, educational, housing, and law enforcement domains. The Council's main focus is HIV prevention and services to persons with HIV/AIDS. Formed in 1988, its main financial support comes from CDC. In addition to sponsoring an annual conference, the Council provides educational workshops in parks and public housing projects.

South Carolina AIDS Education Network, Shear Devotion, Nurturing the Tree of Life, and AIDS Busters are organizations that deliver STD risk reduction messages in places where people gather informally, such as hair salons, barber shops, night clubs, and liquor stores.

Orangeburg-Calhoun-Allendale-Bamberg (OCAB) Community Action Agency is a well-regarded participant in general health promotion activities, although syphilis is not as high a priority as teen pregnancy prevention, maternal and child welfare, and HIV prevention. The Agency has a peer educator project among adolescents and young adults (ages 13-24) focusing on HIV/AIDS. Peer educators are trained by the American Red Cross and the AIDS Busters program based in Columbia. The project enjoys the cooperation of several local churches and community centers.

Appendix D4 - Case Studies of Shelby County, Tennessee, and Tunica County, Mississippi

D4.1 Community Profiles

The case study pair reported on in this section represents geographically proximate communities in too different states: Shelby County, Tennessee (urban), and Tunica County, Mississippi (rural).

D4.1.1 Shelby County (Memphis), Tennessee Urban

Geographic Characteristics

Shelby County, home to the City of Memphis, is in the southwestern corner of Tennessee. The Mississippi River forms the western border of the city and county. The metropolitan Memphis area extends into Arkansas, across the river to the west, and into the extreme northwestern portions of Mississippi, immediately to the south of Shelby County.

Memphis is centrally located between New Orleans and St. Louis, and Dallas and Atlanta, making the city a major regional distribution hub. In addition to the barge routes on the river and corresponding rail lines, two major interstate highways intersect in Memphis; I-55 runs North to St. Louis and South to New Orleans. I-40 runs East to Nashville and Raleigh, North Carolina, and West to Little Rock, Arkansas.

Demographic Characteristics

The City of Memphis had a population of 610,337 in 1990, while the metropolitan area as a whole (including counties in Arkansas and Mississippi) totaled 863,898. The citys population decreased by about 35,000 between 1980 and 1990, while suburban portions of the metropolitan area increased during this period by almost 100,000.

Within the City of Memphis, African Americans made up about 55 percent of the population in 1990. The portions of the metropolitan area outside the city were 86 percent white, and only 14 percent African American. Hispanics, Asians and Pacific Islanders, and American Indians made up less than 1 percent of the areas population in 1990. A local organization is involved in providing shelter to Chinese refugees, accounting for a slight increase in the Asian population. Over 75 percent of persons 25 and older in Shelby County have completed high school. Nearly 21 percent of this group have also completed college or a higher degree.

Economic Characteristics

The Memphis area economy takes advantage of its central location as an active transportation and distribution hub. The Federal Express Corporation has its central operations based in Memphis and, with more than 23,000 workers, is the areas principal employer. Other major employers include educational institutions and area hospitals. Jobs in the service industry account for 27 percent of the labor market in the metropolitan area. Retail, government, and manufacturing account for an additional 46 percent of the labor market.

While employment, household income, and other indicators reflect a generally prosperous regional economy, this prosperity is not evenly distributed. Area residents enjoy a higher per capita income than the US as a whole, but per capita income for the areas white residents ($18,175) was more than double that of the areas African-American residents ($7,262). About 35 percent of the metropolitan areas African-American residents live in households below the poverty level, compared with less than 7 percent of the areas white residents. More than 50 percent of all black children under the age of 5 years live in households below the poverty level, compared with less than 9 percent of the areas young white children (US Bureau of the Census 1994b).

Social Characteristics

According to local residents, the social situation in downtown Memphis has changed in the past 10 to 15 years. In 1980, there was a high likelihood of being accosted or robbed in the downtown area. Public and private investment and redevelopment efforts have improved the downtown area, making it safer for tourism and recreation. In other areas of the city, crime is still a problem, despite the presence of 2,000 law enforcement officers (1,300 city police officers and 700 Shelby County Sheriff's Department deputies). Memphis is also beginning to have a problem with street gangs, such as the Gangster Disciples out of Chicago, the Crips and Bloods out of Los Angeles, and a local set called the Four Corners Hustlers.

Throughout Memphis, one finds lower-, middle-, and upper-income neighborhoods next to one another. Public housing projects have been distributed throughout the city, rather than being concentrated in one part of town. Neighborhoods with public housing include Binghampton, Orange Mound, Hurt Village, Little Chicago, Lemoyne Gardens, Foot Homes, Getwell Gardens, and Dixie Homes. Ten to fifteen years ago, crime was concentrated in certain neighborhoods in the city, but we were told that is now distributed throughout the city.

Prostitution is reportedly a major problem in Memphis and is more likely to be found in certain areas, most prevalent in north and south Memphis. Prostitutes often wait for customers at bus shelters, because it is an acceptable place to be seen standing around. Male prostitutes loiter at the labor office where they can pick up temporary day laborers who just got paid.

Binghampton is a low-income area of the city, with about 10,000 people, 95 percent of whom are African American. The neighborhood is split evenly between home owners and renters. Despite 14 churches in the neighborhood, we were told that many people attend church elsewhere. There is one elementary school in the neighborhood with 700 kids, and a large apartment complex with about 1,000 units, which is low-income HUD housing. Young girls often take apartments there because they have AFDC income and no credit problems. One neighborhood activist told us that the girls then bring in a lot of boyfriends, who introduce crime to the neighborhood.

The Binghampton neighborhood also has a problem with hourly motels. We were told that several of the hotels in the area have gone to an hourly rate to increase revenues. Regulation of the hourly hotels is difficult due to a law that allows them because they are needed by truckers. However, the hourly hotels are said to be used for prostitution.

Another area with a high rate of poverty is Court Street, near Cleveland and Jefferson. Housing in the area is almost exclusively apartments, with very low levels of home ownership. The area has a growing population of Asian refugees because it is near the Catholic Charities Refugee Resettlement Program. Street prostitution is common there also. Other low-income areas may be found around the intersection of Lamar and Winchester and near Graceland. One small housing project, Getwell Gardens, is known by locals as the crack center of Memphis.

Approximately 107,000 students are enrolled in Memphis City Schools. Of that number, 88 percent are African Americans. The majority of white children attend either the county schools or private schools throughout the city. Church-based private schools are common as well.

In 1994, the Regional Medical Center (the Med) almost closed because of budget shortfalls. The community perceives of the Med as vital to its functioning, so residents rallied behind it, and the state government identified some operating funds. The Med ended up laying off large numbers of staff instead. At the time of our site visit, the Med was operating with a million dollar deficit.

Health Care

Tennessees 95 counties are divided into 13 public health regions. Each of six metropolitan counties constitute separate public health regions (Memphis, Nashville, Chattanooga, Jackson, Johnson City, and Knoxville). The remaining 89 counties are divided into 7 regions. Memphis/Shelby County operates as one administrative unit under the Tennessee STD/HIV program. Counties surrounding Shelby County are part of the West Tennessee Public Health Region.

Hospitals. Memphis has five major hospitals: Methodist Hospital, the Regional Medical Center, Baptist Hospital, St. Jude's Children's Hospital, and the Veterans Administration Hospital. The Regional Medical Center, referred to as The Med, is the only public hospital in Memphis; it was almost closed in 1995, but civic efforts led by the Mayors Office helped to keep The Med open. Many departments were restructured, and a large number of employees were laid off. Recent changes do not appear to have affected The Med's ability to meet the areas medical needs.

Primary care services. Primary care services are provided to working poor and medically under-served area residents mainly through the Memphis Health Center, the Church Health Center, Brannon-McCulloch Clinic, and the Mid-South Family Health Care Center. In addition to its central facility (where the STD clinic is located), the Memphis-Shelby County Health Department operates six satellite clinics, which are distributed throughout the city in low-income areas. The satellite clinics offer immunizations, well-baby care, and other primary care services. All STD testing and treatment is done at the central facility. Until recently, HIV counseling and testing were done in a separate location in the Health Department building. Now, all STD and HIV services are located in the same clinic. STD patients are charged $8 for testing and treatment if they come in for a scheduled appointment. Patients referred by Disease Intervention Specialists (DIS) are seen for free.

Health care for low-income residents. The Church Health Center (CHC) provides primary care services to the working poor in Memphis. CHC is supported by individual donations from over 150 congregations in the Memphis area. This project is strongly supported by the local medical society. Day and evening hours help make the clinic more accessible to working patients. Evening hours are staffed by volunteer physicians, nurses, and dentists. CHC has developed a lay health advisor program through which they train church members to provide health care information to the congregation. Lay health advisors attend an eight-week training course covering hypertension, STDs, prenatal care, and diabetes.

State managed care. Tenncare is a statewide program to provide health care coverage to the uninsured. Tenncare was designed to replace Medicaid and other health entitlement programs. Program participants can choose to enroll in one of five managed care plans. Participants who do not choose one of the plans are automatically assigned to one. Most medical facilities in Memphis accept at least one of the five managed care plans. Local health officials report that many Tenncare enrollees appear to be unclear about how the system works. For example, a provider the enrollee visits may not accept the plan in which he/she is enrolled. Local health officials and community representatives believe that confusion about the program may keep some program participants from seeking health care.

D4.1.2 Tunica County, Mississippi Rural

Geographic Characteristics

Tunica County is located 35 miles south of Memphis, along the Mississippi River on Highway 61. The County is part of the Mississippi Delta Region, and most of the County's land is used for farming. The town of Tunica is the largest population center and only incorporated municipality in this rural county.

Demographic Characteristics

The County had 8,146 residents in 1990, about 2,000 of whom lived in the town of Tunica. Seventy five percent of the population was African American and 24 percent white. The remaining 1 percent of the population was mainly Hispanics. The total population in the County decreased by 15 percent between 1980 and 1990. The white population decreased by nearly 30 percent during this period, while the non-white population decreased by nearly 13 percent. Since 1990, gaming and tourism developments along the river have resulted in job growth, but not a significant increase in the County's population.

Economic Characteristics

Unitl recently, Tunica County's economic base has been mainly agricultural. The major employers in 1996 are the casinos, Pillowtex and Battle Farms, a large family-owned cotton and catfish operation. Since 1992, 12 casinos have opened up at the north end of the County. Four of these are no longer in operation ironically, the casinos that have closed down were all located closest to the Town of Tunica. Most of the casino development is now under way several miles out of town. The casinos have provided jobs for many Tunica County residents, but 1995 unemployment in the County (10 percent) was still above the statewide average (6.1 percent) (US Bureau of Labor Statistics 1996).

By the beginning of 1996, almost 10,000 people were employed at the casinos in Tunica County. Most of the casino jobs have been filled by people commuting from outside the County. We were told that a number of high school youth work in the casinos; they often go straight from school to work, which is said to leave them less idle time for getting into trouble. Tunica County AFDC and food stamp recipients were reduced by nearly one-third as a result of the new found prosperity.

The casinos local economic impact is generally regarded with favor. Local opponents generally object to negative influences of gambling on the community. While the casinos generate substantial tax revenues for Tunica County, public investment has to date emphasized improvements in roads and other infrastructure to support the casinos. Improved community services have received a lower priority.

Social Characteristics

Educational institutions in Tunica are almost completely divided by race. Students at the public schools are over 90 percent African American. White children attend the Tunica Institute of Learning (TIL), a private school established when desegregation laws were passed. We were told that TIL has perhaps two or three African-American children enrolled. Until recently, the public school in Tunica was in Level 1 (at risk) status in terms of standardized test scores. The physical facility was deteriorating and supplies were seriously lacking. Since a law was passed mandating that 12 percent of tax revenues from the casinos go to the public schools, the situation has improved somewhat, and test scores rose in 1995-96 to a Level 2 (probationary) status.

Health Care

Tunica County is one of nine counties in Mississippi Public Health District 1. The central office for District 1 is in Batesville, Mississippi, in the southeast corner of the District.

Health Department clinic. The town of Tunica has a Health Department clinic with one full-time nurse and another nursing position that was vacant at the time of our visit. A coordinating nurse, who is responsible for both Tunica and neighboring Tate County, spends two days a week in Tunica and three days in Tate. The Tunica clinic also has an office manager, a social worker, two medical aides, and an environmental health expert on its staff. The Tunica clinic sees about 25 to 30 patients each day.

The Health Department clinic in Tunica is open from 8 am to 5 pm on weekdays and begins seeing patients at 9 am. It has a large family planning program, which includes STD testing, treatment, and counseling. Although the clinic makes appointments, people with STDs usually walk in. In the clinic's waiting room condoms are available free of charge.

In Public Health District 1, one DIS supervisor is based in Batesville, along with six DIS. A single DIS staff member is responsible for both Tunica and Quitman counties. The DIS are able to spend the majority of their time in the field, while the clinic staff manage the contacts who are sent in.

Other primary care facilities. Other health care facilities in Tunica include a satellite clinic of the Aaron E. Henry Community Health Center (AEH) and the Methodist Family Medical Center, both described further below. Additional service providers outside of the county include Baptist Desoto Hospital, 30 miles away, and the hospital in Clarksdale.

Aaron E. Henry Community Health Center. AEH is a federally qualified health center, with its central office and a clinic in Clarksdale. In addition to the Tunica clinic, two other satellite clinics are located in Coahama County, and AEH also operates two school-based clinics (one of which is in Tunica at the Rosa Forte school).

The Tunica AEH clinic has 12 staff members, including two nurse-practitioners, two permanent physicians, one pediatrician who comes in on Fridays, a nurse-midwife who comes in on Wednesdays, and a nutritionist who comes in twice a week. The clinic accepts both appointments and walk-ins. We were told that walk-ins may have to wait a little longer. The AEH clinic offers general medical care, physicals, obstetrics, WIC, diabetes and geriatric care.

We were told that 95 percent of the clients at the AEH clinic are African American. A large percentage of patients at AEH pay with Medicare and Medicaid, and a sliding-fee schedule is used for indigent patients. AEH also has a fund to pay for the cost of prescriptions for people with life-threatening and chronic illnesses. AEH has a contract to provide health care to the workers building the new Grand Casino in Tunica and a public transportation system funded through a grant from the Mississippi Department of Transportation and from Medicaid Transportation. Although the system has a set route, it will respond to people who call and make an appointment.

AEH opened a school-based clinic in Tunica at the Rosa Forte public school in 1991, open from 8 am to 4:30 pm every school day. The Rosa Forte school contains both the elementary and high school, and the clinic is housed in the elementary portion. The school-based clinic has a nurse practitioner, an LPN, and a receptionist. The same pediatrician who serves the AEH clinic also serves the school-based clinic once a week. This pediatrician is shared with the children's clinic in Clarkesdale and is 50 percent funded by AEH. The school-based clinic handles screenings, accidents, and family planning. The school clinic will also take care of the babies of teen parents when the pediatrician is there.

In addition to its clinic staff, AEH has health educators who serve Tunica, Quitman, and Coahoma Counties. They primarily cover STD/HIV prevention and try to be visible in the communities, churches, and schools. The health education staff were trained by the American Red Cross based in Jackson, Mississippi.

The Methodist Family Medical Center. The Methodist Family Medical Center in Tunica is housed in the building that used to be the Tunica Hospital. The facility is owned by the Methodist Primary Care Association out of Memphis, where the Methodist Central Hospital is located. One full-time and one part-time physician and a nurse practitioner are on duty at the Tunica facility. The operating hours are from 8 am to 8 pm seven days a week, although a practitioner is not always on site. If a patient comes in with an emergency during evening hours, the doctor can be called in.

Most of Methodists clientele are enrolled in Medicaid and span all age groups. Patients are mostly African Americans, and Methodist sees a large elderly population. Methodist also does some follow-up for the Health Department, including for hypertension, hepatitis, TB, skin infections, baby formulas, and upper respiratory problems.

Factors influencing selection of health care providers. Local providers describe Tunica residents as inclined to do a lot of shopping for health care. People will go to the facility with the shortest wait, which can disrupt continued primary care. Besides the length of waiting times, another factor that influences the choice of health care providers is the method of payment that providers will accept. People will go to the Health Department for free services, and those with Medicaid or cash will go to AEH or Methodist. One community member said that African Americans will usually go to AEH for care, while whites go to Memphis or, for emergencies, may go to Methodist.

D4.2 Key Assessment Issues

D4.2.1 Who is at great risk of acquiring/transmitting syphilis

The factors thought to contribute to heightened risk of syphilis infection are similar in the urban and rural sites. Some distinction was made between those who are at greatest risk of acquiring syphilis and those most likely to transmit the disease. In both the urban and rural site, syphilis primarily affects poor, young African Americans. Some public health workers and staff from community-based organizations expressed concern about reporting bias, because whites are more likely to go to private physicians instead of the Health Department clinic, and cases treated by private physicians are thought to be under-reported. Opinions differ among those interviewed about the extent of reporting bias.

Below we discuss the major risk factors identified by our respondents, first for the urban, then for the rural site.

Shelby County (Memphis), Tennessee Urban

Age and race. Health Department statistics show syphilis primarily affects African Americans between the ages of 20 and 29 living in high-poverty areas. Some of those interviewed reported that even younger people, aged 15 to 30 years, were considered at high risk for syphilis. The teen pregnancy rate in Memphis is believed to be very high, and people working with teens believe the risk of STDs is high in this population.

Socioeconomic status. Low socioeconomic status was identified as a risk factor by the majority of health care providers, public health agency, and community-based organization staff interviewed. The Health Department has mapped syphilis cases by census tract and found that cases form a horseshoe around the city. The horseshoe begins in the north at Hurt Village, follows the Parkway on the west of the city to Orange Mound, then south all the way to the Mississippi line. Particular neighborhoods considered to be high-risk areas are Hurt Village, Binghampton, Orange Mound, Little Chicago, Lemoyne Gardens, Foot Homes, and Dixie Homes. One respondent suggested that Poverty is a risk because sex is free when there is nothing else. From this viewpoint, people living in poverty are said to be dealing with basic needs on a daily basis and may not consider STDs a priority. Through its surveillance activities, the Health Department has identified certain high-incidence areas, and Hurt Village was the target of a recent emphasis program by DIS staff.

Gender. Men and women are equally affected by syphilis, but women are said to be more likely to be tested because they are more engaged in the health care system. Young African-American men typically have very limited utilization of health services in Memphis and are thought to be more likely to go untested and untreated. Several respondents suggested that women are more likely to acquire syphilis, while men are more likely to transmit the disease. A staff member from a community-based organization suggested a typical scenario: young women develop short-term relationships with men who offer them something of value (e.g., gifts, toys for their children, clothing, small amounts of money). This value is limited, however; not sufficient inducement to remain involved in any particular relationship for very long. The result is multiple sexual partners. Poor women often become sexually involved with a series of partners to improve their socioeconomic status for themselves and their children. While the arrangements may help to support a family, it also places the woman at risk for syphilis and other STDs.

Substance abuse. Most of those interviewed thought that crack use is strongly related to syphilis; we also heard a few dissenting opinions. We interpreted the assertion that no significant relationship exists between crack and syphilis as reflecting a complicated set of risk factors, rather than an over-simplification of the behaviors that elevate ones risk for syphilis infection. Among those who believe that syphilis and crack use are related, most felt that people are trading sex for drugs or money to buy drugs. The addiction to crack is so strong that people will do anything to support their habits, and this addiction further prevents people from thinking about risk or protection from STDs. Intravenous drug use is not reported to be a significant problem in Memphis. We heard from some respondents that alcohol use is also strongly related to syphilis.

Those trading sex for drugs are said to consider themselves amateur prostitutes and usually know the people with whom they have sex. Crack has also fostered bargain basement prostitution, where women may trade sex for as little as four dollars, snack food, or a can of soda. A representative from one community-based organization mentioned that in most crack houses you get the woman with the rock. You do not pay her, you just give her a little pinch off the rock. Oral sex is most often traded for crack because it is quick and easy. One public health agency staff member remarked that one whole category of crack users live their lives in 15-minute segments: 15 minutes on crack, 15 minutes of sex, 15 minutes of crack. While it is said to be mainly females who follow this pattern, males are also among those trading sex for drugs.

Commercial sexwork. Commercial sex work is also prevalent in Memphis. Unlike their crack-addicted counterparts, however, professional prostitutes are said to be more likely to take care of their health in order to earn a living. Bus shelters are a common place for female prostitutes to solicit customers, because the bus shelter is an inconspicuous place to stand around. Street prostitutes are more likely to attract customers who drive in from the suburbs than are crack addicts trying to feed their habit. The Health Department has recently been enforcing a communicable disease law that was established in 1927 to control typhoid fever. The law states that anyone can be arrested, quarantined, and tested if they are suspected of having a communicable disease. The Health Department has been focusing on prostitutes. They have found that about 30 percent of those they bring in test positive for syphilis.

HIV and other STDs. Respondents share the general belief that people at risk for STDs are also at risk for HIV, but most have not seen evidence of co-infection in their clients. In certain populations, such as the homeless and the chronically mentally ill, HIV and other STDs appear to be more closely related than in the general drug-using or low-income populations. Health Department staff report that they used to encourage HIV testing for STD patients, but they have discontinued the practice because they felt the test results showed that the association was not strong.

About 15 percent of syphilis patients treated at the Health Department are treated for repeat infections. It is difficult to generalize about who is most likely to be treated for repeat infections, but all the anecdotal references we heard to such patients concerned men who are characterized as difficult to reach with traditional educational methods. The clinic staff and DIS workers attempt to talk with these patients about prevention, but do not believe they have much influence. Clinic staff report that repeat patients know all they have to do is come into the Health Department for a shot.

Tunica County, Mississippi Rural

Tunica indeed, the entire Mississippi Delta region is considered to be a high-risk area for syphilis as well as for HIV/AIDS. The number of AIDS cases has increased in the last year and people feel that this trend will continue. The same behaviors (unprotected sex, multiple partners) are thought to place people at risk for syphilis and HIV. Once HIV is introduced into the local population, rapid transmission is possible.

Age, race, gender. African Americans between the ages of 15 and 30 are considered to be at greatest risk for syphilis in Tunica County. Females are more likely to be treated for syphilis because they are engaged in the health care system, but it seems that men and women are at equal risk. Recreational activities are limited for young people in Tunica County. The social scene is centered in a few clubs or juke joints located in the town. Most of the people in the clubs are teenagers, it is reported, because the town offers few other forms of recreation. Multiple sex partners and promiscuity seem to go along with drug and alcohol use. Teen pregnancy has been considered a formidable social problem for several years. For some girls, a baby is a status symbol, attracting the attention of boys. Young girls are also said to be having sex with older men because the men are paying the bills.

Socioeconomic status. Poor economic conditions are thought to be another risk factor for syphilis. Tunica County continues to be one of the poorest counties in the United States. Referred to as the Ethiopia of the South, Tunica figured prominently in Jesse Jackson's 1984 Presidential campaign. Economic conditions in the County have improved due to recent casino development, and DIS staff partially attribute the recent decline in syphilis to improved economic conditions. More jobs have been created, so people have less idle time on their hands. However, health care providers are concerned that the casinos attract people from outside the County, which may lead to an increase in syphilis and other STDs. They suspect the incidence of STDs will increase as economic development in the County continues.

Substance abuse. Drug use and alcohol are thought to be strongly associated with syphilis and other STDs. One health care provider remarked, there just isn't much to do here ... a lot of people get involved with drugs and alcohol because there isn't anything to do. Crack has quickly spread throughout Mississippi, and increased syphilis rates have followed. A strong drug connection, commonly referred to as the Chicago-Grenada connection, has been noted for several years. Although little evidence to date confirms this, many also feel that drug trafficking will increase because of the casinos. According to a Health Department staff person, Crack has gone country. Crack houses can be started in rural areas and no one will know it's there for a long time.

Commercial sex work and trading sex for drugs. Prostitution as an industry does not really exist in Tunica; however, trading sex for drugs is said to be quite common. Organized prostitution may become more prominent as the casino industry flourishes, but it is limited at this time. People in the community are reported to know who is trading sex for drugs through word of mouth.

Women who trade sex for drugs are seen repeatedly at the Tunica County Health Department. Local officials say that the repeat infection rate for STDs is extremely high in Tunica County. Approximately 75 percent of the patients at the Aaron E. Henry Clinic are people who have previously been treated for an STD. DIS staff feel they are contacting and treating the same people over and over again.

D4.2.2 What institutions are thought to be most likely to reach those at greatest risk

In Memphis and Tunica County, many institutions are actively working to reach people at the greatest risk. In both sites, respondents identified ways to make the current institutional responses more effective, as well as other institutions that have the potential to reach those at greatest risk. Poverty, however, is a major barrier to effective institutional responses to syphilis and other STDs. Below we discuss local institutions first in the urban, then in the rural site.

Shelby County (Memphis) Urban

Health department. The Memphis/Shelby County Health Department is the principal organization working with syphilis in Memphis and Shelby County. The majority of health care providers in the city and county refer patients to the Health Department for STD testing and treatment. About 120 patients are seen in the STD clinic each day. One physician is available on an irregular basis and six nurses are on staff at the clinic to treat patients.

The Infectious Disease Division of the Memphis/Shelby County Health Department has 18 DIS staff, who rotate through three teams: surveillance team, field team, and jail team. The surveillance team remains in the clinic, interviewing infected patients. Field team members alternate one day in the clinic, one day in the field tracing contacts. The jail team does interviewing and orders tests under the supervision of medical staff at the jail. Traditional infection control methods, shoe leather epidemiology, are used to control syphilis and other STDs. Health Department staff and other respondents feel that targeted outreach, neighborhood screenings, and other less traditional methods that are currently not emphasized would be well received in the community and are potentially effective ways of reaching those at greatest risk.

Schools. The Memphis City Schools are also thought to have the potential to reach the populations at greatest risk. A lifetime wellness curriculum is currently in place, but sex education continues to be controversial due to opposition from conservative groups. Programs exist within the school system for identified high-risk children, like the Pregnant Teen and Parenting program, which provides education and follow-up. A number of those we interviewed emphasized the need for more proactive sex education and prevention programs in the school system.

Religious institutions. Churches may be the single most powerful and influential set of institutions in Memphis. Public health agencies and community-based organizations have attempted to involve churches in STD/HIV prevention activities with varying degrees of success. Planned Parenthood has successfully implemented a parent-teen communication project that is administered through churches. Churches have also been directly involved reaching out to those at greatest risk. For example, the Mississippi Boulevard Christian Church runs the Healing Arms Ministry. This ministry is a spiritually based support group for people with HIV and AIDS and their families. Many respondents suggested other methods to involve churches in STD prevention (e.g., teen peer counseling services, training for lay health workers, services for the homeless, residential centers for substance abuse treatment, financial support for prescription drugs), but also expressed general concern regarding the conservative nature of churches in the South.

The Church Health Center (CHC). CHC has volunteer physicians, nurses, and dentists providing primary care services to the working poor in Memphis, with day and evening hours. CHC also operates a lay health advisor program through which they train members of local churches to provide health care information to their congregations, including STD education.

Community-based organizations. A number of community-based organizations are implementing programs that address the immediate health needs of at-risk communities, while also focusing on broader issues such as education and economic development. Three particularly successful programs were identified for us Project Success in Hurt Village, Project Vision in Binghampton Neighborhood, and ECHO (Empowering Choice Healthy Opportunities) in Lemoyne Gardens administered by the West Tennessee Health Education Center. Each of these programs has targeted activities to specific needs of a clearly defined population. We were told that many other poor neighborhoods are in need of similar programs. One representative of a community-based organization suggested that community development in Memphis is motivated by which housing project is the flavor of the year. With this year-to-year approach to project definition, long-term sustainability of community development efforts is a concern.

Tunica County Rural

Tunica County is a small, rural community with few formally instituted ways to reach those at greatest risk for syphilis. Health care facilities are the most actively engaged institutions involved in outreach activities; complementary efforts from other institutions do not appear to be forthcoming.

Schools. Many respondents considered health education in schools to be the most effective way to reach children and teenagers at risk. The State of Mississippi has adopted a comprehensive health education curriculum, but it is not mandatory. Schools in the surrounding counties have adopted the curriculum; Tunica public schools have yet to do so. In 1996, Aaron E. Henry Community Health Services Center (AEH) was in its third year of providing health education classes to students at the Rosa Forte School. Health educators are not permitted to use anatomical models to demonstrate condoms. Educational materials include cartoons, but not realistic illustrations. Health education messages include abstinence as well as safer sex. If students request condoms, the health educator must refer them to the Health Department or AEH. Local providers told us that in their judgment, health education and STD education in Tunica schools is very limited, leaving substantial room for improvement in delivering effective prevention messages to children.

Community-based organizations. Only a few organizations in Tunica address the immediate health care needs of the community and even fewer are addressing the broader issues associated with poverty. Youth Opportunities Unlimited (YOU) stands out in a community that seriously lacks institutions to reach those at greatest risk for syphilis. The program works with children and teens outside of the school system by teaching abstinence and safe sex. A separate program works with 4th through 6th graders addressing self-esteem building and conflict resolution.

Religious institutions. Churches were identified as a powerful mediating structure in the community, but efforts to work with the religious community have been on an informal basis to date. AEH health educators, DIS staff, and YOU staff all mentioned that they have tried to work with churches, but no formal relationship has been established.

D4.2.3 What are the barriers or facilitators to reaching those at greatest risk

Although many important institutional resources are available in both Memphis and Tunica County, several barriers to reaching those at greatest risk were identified. Common to both sites were references to the conservative orientation of Southern communities. In addition, compliance with fair labor practices requirements, regarded by front-line health care workers as a bureaucratic approach, is said to impede efforts in these locales to implement effective syphilis prevention programs.

Shelby County (Memphis) Urban

Local norms about public discourse on sexuality and sexual health. Many of those we interviewed identified community norms regarding sexuality, STDs, and HIV/AIDS as one of the major barriers to effective prevention programs. People told us that communities are in denial about adolescent sexual activities, STDs in general, and HIV. Comprehensive sex education, including age-appropriate discussions of reproductive anatomy and physiology, is not taught in the schools. Several representatives from community-based organizations said that they specifically avoid developing school programs because of the bureaucracy and controversy. Few churches address STD or HIV prevention, and those that do focus exclusively on moral dimensions (with reference to the wrath of God and adultery) without addressing public health issues.

Local priorities. Barriers relating to access and utiliation included: (1) emphasis of treatment over prevention, (2) restrictions on employee hours, and (3) lack of unified message.

Emphasis of treatment over prevention. Syphilis treatment and control are given relatively high priority by the Memphis/Shelby County Health Department. The focus is on surveillance and contact tracing, while prevention and education receive less emphasis. The higher priority placed on treatment may be evident in only the subtlest of indicators: the Health Department distributes free condoms, for example, but has recently limited the number of condoms available to patients to four per visit.

Bureaucratic restrictions on employee hours. Recent restrictions on Health Department staff hours limit the effectiveness with which DIS staff can extend their prevention and education activities. Stricter enforcement of the federal Fair Labor Standards Act has resulted in tight controls over the number of hours worked by non-exempt staff, including DIS and Health Department clerical staff. DIS staff feel that it would be more effective to work some evenings and weekends to locate difficult contacts, but flex-time schedules are difficult to approve under current restrictions.

Lack of a unified message. While the Health Department focuses on syphilis as a distinct public health problem, other Memphis organizations address syphilis prevention within the context of HIV prevention or pregnancy prevention. We heard from many different sources who felt it would ultimately be more productive not to separate syphilis out from other STDs. Prevention messages are thought to be more effective if they address modifying behaviors that place individuals at risk for HIV and STDs.

Barriers to access and utilization. Barriers relating to access and utilization included: (1) Medicaid managed care, (2) clinic location and fees, (3) transportation issues, (4) the appointment system, and (5) testing issues.

Medicaid managed care. Tenncare the statewide program providing health care to the uninsured was cited by nearly everyone we interviewed as the foremost barrier to access and utilization of health care. The plan is extremely confusing to patients and providers alike. Card holders are assigned plans and often do not know where they are allowed to go for medical care. One public health agency staff member commented that the only way to learn how to get medical care with Tenncare is to bounce off the walls until you find someone to treat you. Many people interviewed shared stories describing how difficult it is for patients to figure out what to do and where to go on Tenncare. Before Tenncare, people on Medicaid would go to The Med for treatment, and no one was turned away. Now that The Med is a provider under Tenncare, the facility can only accept patients enrolled in specific plans. A result of the confusion about plans and providers is that substantial numbers of people are not seeking treatment. Efforts are being made to sort out the confusion with Tenncare; however, these efforts do not appear to be coordinated.

Clinic location and fees. We heard from some respondents that the location of the Health Department STD clinic may present barriers to effective testing and treatment of syphilis. The clinic fee may deter patients with limited financial resources. Health Department management prefer the centralized STD clinic so that testing, treatment, and control efforts are easily monitored. Several public health agency staff and representatives from community-based organizations felt it would be more effective to have testing and treatment facilities in easily accessible satellite clinics.

Transportation issues. Some people felt that public transportation was a problem, while others thought the bus system was accessible and convenient. Access to the STD clinic is further limited by local parking problems. The building has off-street parking, but too few spaces to accommodate patients and staff. Limited metered spaces are located on the streets surrounding the building, but they are expensive and usually full. Bus fares may deter patients with limited financial resources.

Appointment system. Several years ago the STD clinic converted to an appointment system, and this has reduced some waiting room congestion. Walk-in patients are still accepted, but the nurses attempt to limit potential walk-ins by doing triage with those patients who call before coming to the clinic. Nursing staff members told us that patients continue to comment on the long wait, although the staff feel that waiting times have significantly decreased. It continues to be a common perception in the community that if you go to the STD clinic you will be waiting all day. In addition, when patients referred to the clinic by the DIS arrive in the waiting room, they are supposed to be seen right away, even if they do not have an appointment. However, these referral patients do not necessarily tell the nurse they have been referred by the DIS and may be forced to wait. When the DIS learn that patients they have referred get discouraged and leave, they tend to feel their efforts have been less than productive.

Testing issues. DIS staff expressed some concern about patients who had a reactive test at another site and were then referred to the Health Department for treatment. The Health Department staff is required to retest the patient. If the blood is non-reactive, the patient is not treated and is sent home. One DIS staff person remarked, ... you beg, bribe and threaten the patient to come into the Health Department and then they are not even treated.

Tunica County Rural

Local norms about discourse on sexuality and sexual health. Many of those interviewed commented on promiscuity among young people in Tunica, but adolescents are difficult to reach with prevention messages. People feel that STD prevention is important, but very difficult to discuss openly in a conservative community.

Concerns about confidentiality may also prevent people from seeking treatment for STDs at the Health Department. In Tunica, the Health Department staff report that the general view is that visits to the Health Department are for one of two reasons, the WIC program or the STD clinic. If you are not pregnant or if you do not have a child, people assume you are visiting the clinic for an STD. Many people in the community are said to believe that the Health Department keeps and distributes a list of STD patients. DIS staff have spent a great deal of time convincing people that no list exists and that all services are confidential. Possible public embarrassment prevents some people from getting treated for STDs.

Local priorities. Two priorities rated higher by the community than STD prevention were: (1) poverty and (2) teen pregnancy and substance abuse.

Poverty. In Tunica County, 50 percent of households live below the poverty level. For many people, the difficulties one faces in keeping a roof over one's head place health issues as a lower priority. County residents face other difficult social issues such as unemployment, illiteracy, general economic under-development, a substandard educational system, and limited access to basic primary health care. With so many unmet basic needs, STD prevention is not a top priority, either for individuals or for the population as a whole. Economic improvements have accompanied casino development in the past four years, and it is possible that public health issues will receive a higher priority as other local problems are eliminated or reduced.

Teen pregnancy and substance abuse. Respondents were most concerned about high teen pregnancy rates and drug use among young people. AEH, the Health Department, and YOU are working together to address these problems. The teen pregnancy rate has dropped over the last few years, but it is still one of the highest in the United States.

Barriers to access and utilization. Lack of health care providers was identified as the major barrier to reaching those at greatest risk in Tunica County. AEH and the Methodist Clinic are the only two health care facilities serving the community, and clinic hours are limited. In addition, many people lack adequate transportation and are unable to reach health care providers for treatment. Although AEH and Catholic Charities in Clarksdale provide free van services to as many people as resources will permit, transportation remains problematic for many residents.

Public health staff recruitment and training. Barriers related to staffing included: (1) physician retention and (2) support staff issues.

Physician retention. Physician retention is an ongoing problem for health care facilities in Tunica. The physician staffing the Methodist Clinic has worked in Tunica for several years. AEH is staffed by public health service doctors. Sixteen doctors have worked at AEH between 1993 and 1996. The doctors are passing through and are not considered part of the community. In general, doctors in the Mississippi Delta region are characterized as overworked and underpaid, and it is difficult to attract providers who will stay for any substantial time period.

Support staff issues. The Health Department is staffed by one full-time nurse, and another full-time position remained vacant for several months in 1995-96. A nurse from Quitman County splits her time between two Health Departments to cover the vacant position. The nurses have standing orders to treat patients diagnosed with syphilis. In the past, some nurses have reported feeling uncomfortable giving bicillin without a doctor present, but this has improved with the statewide effort to train nurses in syphilis treatment. All nurses complete a four-day STD workshop and attend annual update meetings in Jackson or Batesville. New hires complete a three-month orientation and are assigned to work with a nurse or DIS staff for on-site training. Several nurses in the region have also attended a one- to two-week STD training at the University of Alabama/Birmingham.

D4.3 Innovative Strategies

In both Memphis/Shelby County and Tunica County, innovative programs exist that address multiple social and health issues including STDs.

Community organizing and coalition building in the urban site. Efforts at community organizing and coalition building included working with: (1) agencies and CBOs involved in STD prevention, (2) community outreach, (3) satellite clinics, (4) teen pregnancy prevention, and (5) the religious community.

Public agencies or CBOs involved in STD prevention. The Memphis/Shelby County Health Department has actively pursued collaborative relationships with other public agencies or community-based organizations (e.g., Operation Street Sweep, a joint Health Department/ Memphis Police Department Organized Crime Unit program, and Hurt Village). Health Department staff operate within an informal network of organizations working with STD prevention and control, including criminal justice and mental health agencies, and community-based organizations.

Community educational outreach. DIS staff and health educators can also participate in the Health Departments Information and Education Committee. This committee gives STD and HIV prevention presentations on request to schools, churches, and other community groups.

Satellite clinics. The Health Department recently tested a satellite clinic in collaboration with Project Success, a social service/community development project in the Hurt Village public housing community. Residents had asked that Health Department services be made available on site in the housing project. The Health Department set up a small satellite office for immunizations, family planning, and STD testing. Operating restrictions limited eligibility to Hurt Village residents and first-time contraceptive users. The Health Department office did not feel the clinic was serving enough patients to be considered cost effective and so closed the office in June 1995 after 18 months of operation. This pilot program offered several valuable lessons learned. The Health Department reported that improved access through highly localized services is not enough to assure utilization; one must also make people aware of the services available and the value of using these services. Gaining official approvals is a necessary but insufficient condition to improved utilization of services; community participation in operations planning is also important. And finally, the Health Department reported that after initial interest in the satellite facility, residents attention flagged, only to be piqued again with blitz activities. This suggests that long-term interventions may not be appropriate in all instances.

Teen pregnancy prevention. Public health and community-based organizations have coordinated efforts addressing teen pregnancy. Planned Parenthood and Project RAP (Responsible Adolescent Parenting) are two organizations, in particular, that are working to address the needs of high-risk adolescents. Both organizations work extensively with other organizations in Memphis. Representatives from both organizations mentioned the need to coordinate efforts so that they do not duplicate services.

Religious community. Several organizations reported efforts to involve churches in STD and HIV prevention activities. While some programs have been successful, churches are generally still reluctant to get involved in such sensitive issues. Health educators from the Health Department conducted a survey among African-American ministers to assess attitudes and behaviors regarding HIV and STD prevention in their congregations. The survey found that ministers typically believe their own churches are unaffected. The West Tennessee Area Health Education Center (AHEC) has also attempted to collaborate with churches and has organized several conferences to promote this initiative. Even though the conferences have been well attended, the AHEC staff felt that the churches arent being very responsive. AHEC plans to continue with this initiative because they hope to develop a channel of religious organizations through which to reach a broader audience.

Community organizing and coalition-building in the rural site. Only a few organizations in Tunica County are involved in health care and social service, and these organizations appear to have little direct involvement in community development and coalition-building. AEH has established the Family Preservation and Family Support program, which provides tutoring and mentoring to children. The program is co-sponsored with local churches and meets in participants' homes to discuss family and community issues. The organizations actively involved in STD prevention and treatment such as the Health Department, AEH, and the Methodist Clinic occasionally collaborate on an informal basis.

As mentioned earlier, the community is sharply divided along racial lines. Little interaction is reported between black and white residents. Blacks and whites go to separate schools, churches, and doctors. This profound racial division poses a barrier to organizing efforts that seek to take full advantage of all the local resources available in the community.

In a number of local programs in both sites, syphilis prevention is addressed as just one part of STD prevention and treatment (as highlighted in italicized phrases of the descriptions below).

Programs through government agencies.

Project Success is a County-sponsored social services/community development program that focuses on a wide range of efforts with the participation of Hurt Village residents. These efforts are acknowledged among innovative public health approaches because of their focus on systemic measures addressing the root causes of community underdevelopment that undermine health promotion at every turn.

Hurt Village Project, an 18-month Shelby County Health Department project that ended in June 1995. The Health Departments Immunization Program had a contract with the City to provide on-site services in Hurt Village, and the STD Program shared space in this pilot program to provide accessible services to Hurt Village residents.

Programs through youth-serving organizations.

Project RAP works with high-risk teens and young children to prevent teenage pregnancy. The project also focuses on responsible parenting for those teens who have already had children. The Rights of Passage program works with 6th-grade boys to encourage nonviolent relationships and alternative methods to resolve conflict.

Youth Opportunities Unlimited (YOU) stands out in Tunica, a community that seriously lacks institutions to reach those at greatest risk for syphilis. The program works with children and teens outside of the school system by teaching abstinence and safe sex.

Programs through religious organizations.

Planned Parenthood conducts a parent-teen communication program with over 60 churches in Memphis and Shelby County. A facilitator from Planned Parenthood provides training, educational materials, and technical support to church members who conduct the sessions.

The Mississippi Boulevard Christian Church operates a street ministry for substance abuse and the Healing Arms Ministry, a spiritually based support group for people with HIV and AIDS and their families.

The Church Health Center (CHC) has volunteer physicians, nurses, and dentists providing primary care services to the working poor in Memphis, with day and evening hours. CHC also operates a lay health advisor program through which they train members of local churches to provide health care information to their congregations, including STD education.

Programs through other CBOs.

Babylove, administered by the Midtown Mental Health Center, offers a support group for pregnant women and new mothers who have a history of substance abuse.

Project Vision is a community development organization serving the Binghampton neighborhood. The project has implemented a number of programs ranging from a health and a fitness program for community residents to an intramural basketball league for children and teens.

Appendix D5 - Montgomery and Lowndes Counties, Alabama

D5.1 Community Profiles

The two Alabama sites were Montgomery County (urban) and Lowndes County (rural).

D5.1.1 Montgomery County Urban

Geographic Characteristics

Montgomery, the birthplace of the Civil War and the modern Civil Rights Movement, is located in central Alabama on the Alabama River. It is situated at the intersection of Interstate Highways 85 and 65. Five US Highways (31, 231, 331, 80 and 82) are routed through Montgomery. This capital city is 164 miles southwest of Atlanta, 92 miles south of Birmingham, and 190 miles north of the Gulf of Mexico (Montgomery Area Chamber of Commerce). In addition, one-third of the population of the United States resides within a 600 mile radius of Montgomery.

Demographic Characteristics

The 1990 census report showed that 187,106 people live in the City of Montgomery, an increase of 4.6 percent from 1980 (US Bureau of Census 1994a). The population for 1996 was estimated to be 198,309. Montgomery County as a whole had 214,996 residents in 1990. The city is 46 percent African American and 53 percent white; the county is 41 percent African American and 58 percent white. The State of Alabama as a whole is about 26 percent African American. Census data show small pockets of Asian and Pacific Islanders and other ethnic groups living in the Montgomery metropolitan area, and fewer than 1 percent are of Hispanic origin.

Economic Characteristics

Montgomery is a regional trade and transportation hub and the site of the Alabama TechnaCenter, a research park developed around Montgomery's growing software engineering community. Montgomery's manufacturing base is diversified, including food/kindred products, transportation equipment, textile/apparel, machinery/equipment, printing/publishing, furniture/fixtures, software engineering, and plastics. The Montgomery area is also noted for its military installations, including Maxwell and Gunter Air Force Bases and Fort Rucker Army Base.

The State of Alabama is the area's largest employer, with 19,000 workers. An additional 9,000 people are employed at Maxwell Air Force Base. Other large Montgomery County employers include Baptist Health Services, Jackson Hospital and Clinic, Auburn University-Montgomery, and Augat Wiring Systems.

In 1996, the median household income for Montgomery is $32,952. Fourteen percent of families in Montgomery are below the poverty level (US Bureau of Census 1994a). Of these, nearly 40 percent are female-headed households.

Downtown and west Montgomery are predominantly poor areas. The most economically disadvantaged neighborhoods include Georgetown Street, West Jackson Street, Midtown/Ferris Streets, and the Virden Addition north on Bailey Avenue Extension. Public housing projects in the city include Tulane Court, Smiley Court, Gibbs Village, Young Fort Village, Cedar Park, and Cleveland (Rosa Parks). New middle class and affluent suburbs are developing in East Montgomery.

Social Characteristics

Gang activity was mentioned as a problem in Montgomery. Most notably, Bloods and Crips, two rival gangs originally from Los Angeles, have local sets. Gang-related graffiti can be seen on West Jefferson Street and west of Court Street. In addition to the crime that gangs are thought to bring to the area, it is also believed that gang association promotes promiscuity among its members, which may have some influence on the transmission of sexually transmitted diseases in an area.

Illegal drugs are also a problem in the area. In the last seven to eight years, crack cocaine use has increased in Montgomery. The drugs are thought to come into the city by way of Florida and Texas on Interstate 65, and possibly Interstate 85 as well. In addition, Interstate 80 is a reputed drug corridor between Mississippi, Alabama, and Georgia. It was said that major drug dealing points are public housing projects and the area north of downtown known as New Town. Respondents also reported prostitution and drug-selling activities concentrated in the city's south end on Mobile Highway.

Relatively few organized recreational activities are available for area teens. The City's Parks and Recreation Department has community centers, but few organized programs to encourage attendance. The established programs do not run every day and are designed mainly for males. In the absence of organized activity, teens spend their time at the malls or cruising (driving around).

The combined Montgomery city and county public school system operates 55 schools with 35,700 students. Sixty-five percent of children attending the Montgomery public schools are African American and 35 percent white, while the city's African-American residents make up close to 50 percent of the overall population. It was reported that a disproportionate number of white students attend private schools. St. Jude's and St. John the Baptist are parochial schools that are predominantly African American. Representing potential teacher training, outreach, and research capabilities are a number of area post-secondary institutions, including Alabama State University, Auburn University-Montgomery, Draughons Junior College, Faulkner University, Huntington College, Southern Christian University, Troy State University-Montgomery, John M. Patterson State Technical School, and H. Council Trenholm State Technical School.

The State of Alabama has no authority to insist on the incorporation of sexual health into school curricula. Control over sex education is vested in the local school boards, many of which resist any discussion of sex in the classroom. The Montgomery School Board is reported to be preoccupied with issues concerning how to finance increases in teachers' salaries, reduction in classroom size, and accommodating new curriculum requirements with a shrinking tax base and increased political support for a voucher system that may only serve to strengthen the private schools. As a result, health education in general and sex education in particular are said to be relatively low priorities for the School Board. When sex education is included in the local curriculum, state law in Alabama dictates an abstinence message.

The absence of a visible sex education program in most schools is attributed to the area's Bible Belt orientation. We were told by many respondents that limitations on sex education in the Alabama public schools is due to the strength of such politically conservative groups as the Eagle Forum and the Concerned Women of America. While these organizations and their supporters exert control over what happens in the public schools, they often send their own children to private schools.

While the church is seen as a very powerful institution throughout the state of Alabama, little evidence can be found of its involvement in efforts to raise public awareness of effective approaches to controlling substance abuse or the spread of sexually transmitted diseases. We were told that most churches in Montgomery are quite conservative and would not be open to messages of STD prevention. We were also told that the churches in Montgomery are almost completely divided along racial lines (with the exception of some integrated Pentecostal churches), making church-based coalition-building in the community more difficult.

Health Care

Alabama is divided into Public Health Areas (PHA) to facilitate coordination, supervision, and development of public health services. Area offices are responsible for developing local management programs of public health services particularly suited to the needs of each Area. As of October 1995, Montgomery County became part of PHA 8. The reporting system has been slow to change, however, and STD cases reported in Montgomery County were still counted in PHA 12 as of February 1996.

Hospitals. Montgomery has four major hospitals, in addition to a Veterans Administration Hospital, a mental hospital, an Air Force hospital, and a rehabilitation hospital. The local hospitals have undergone some changes over the past 10 years. St. Margaret's, operated by the Catholic Church, was the charity hospital in town. It was sold to Humana in the early 1980s, and then to Columbia Health Management, which operates it now as Montgomery Regional Medical Center, a private facility. Fairview was a predominantly African-American hospital that has since closed down.

In the absence of a public hospital, a rotating ER of the Day arrangement was instituted in the late 1980s. To spread the cost of treating people who lack primary care and to balance the distribution of uncompensated walk-ins, Montgomery Regional Medical Center, Jackson Hospital, and Baptist Medical Center alternate as ER of the Day. Announcements for the ER of the Day are made on the radio daily, and ambulance services are aware of which hospital to bring patients to on any given day.

Hospital representatives from hospitals pointed out that because the ER of the Day rotates, they have a difficult time detecting repeaters. Also, no formal mechanism is in place for infectious disease specialists in the different institutions to communicate with each other about repeaters. It falls to the Health Department to detect a pattern of repeat infections.

Primary care facilities. Lister Hill Health Center, which provides multiple services; Montgomery Primary Health Care Center, which is located in the same building at the Specialty Clinic; and Ramer Health Center, are all operated by Health Services Incorporated and provide health care to those without health insurance. These facilities are federally qualified community health centers that have higher medical reimbursement rates for Medicaid and Medicare, lower pharmacy costs, and fees charged on a sliding scale. Although Lister Hill sees a similar clientele to the Health Department, Public Health Representatives told us that many people prefer to seek STD treatment services at Lister Hill because the facility offers multiple services (patients are not presumed to be seeking STD treatment), and because it is located close to two large public housing projects.

To provide low-income women with prenatal and obstetrical services, the Gift of Life Foundation was established in recent years by a group of local physicians. The Foundation is operated by the Montgomery Regional Medical Center in collaboration with the Health Department. Local obstetricians had been delivering many babies at the ER of the Day whose mothers had not received prenatal care and often experienced complications. Many physicians stopped providing care to low-income pregnant women because of the high cost of malpractice insurance. To fill in the service gap, Gift of Life offers prenatal services through the maternity clinic at the Health Department. Nurse midwives and nurse practitioners deliver much of the prenatal care, while obstetricians work with the high-risk mothers. Women can then deliver at Montgomery Regional Medical Center.

In the last few years, several private walk-in clinics have set up business in Montgomery, targeting people without insurance and without a regular doctor. We were told that these so-called Doc-in-a-box facilities have become an alternative to the ER of the Day or the Specialty Clinic for some area residents, but no firm visitation data were available. Montgomery Reproductive Health Service also provides health care to the Montgomery area residents. STD testing and treatment are available there, but services have declined in the last few years due to the need to charge patients for the tests. Planned Parenthood has four offices in Alabama, one of which is in Montgomery.

STD treatment facilities. The Health Department STD clinic, known as the Specialty Clinic, used to be in the central city but in July 1995 moved into the Montgomery County Health Department location on Mobile Highway. This location is right next to a major bus terminal, but bus services have been scaled back significantly in 1995 and 1996, limiting routes and hours of service. The Specialty Clinic can see patients 12 years of age and older without parental consent. We were told by clinic staff that men are more likely to go to the Health Department for care than women. This is because more women have Medicaid and can thus access private physicians.

Montgomery AIDS Outreach (MAO) is a community-based organization that provides services for persons with AIDS, HIV+ persons, and also conducts prevention and outreach efforts in the metropolitan area. MAO operates a clinic at its offices (near Jackson Hospital) five days and four nights a weeks, offers services at the Montgomery County Health Department twice a month, and has opened several rural health clinic sites around the region. MAO also collaborates to some extent with the Chemical Addictions Program, a state-run agency with both a 28-day residential program and an outpatient program that provides treatment for drug and alcohol addiction for Montgomery area residents. MAO clinic staff includes a complement of physicians, RNs, nutritionists, phlebotomist, medical technicians/technologists, and a mental health therapist.

People infected with syphilis generally go to the Health Department for treatment. Since Jackson Hospital has phased out its obstretics and gynecology clinic, any syphilis cases reported there are associated with psychiatric admissions, which themselves are almost always associated with substance abuse. Montgomery Regional Medical Center, on the other hand, observes a different profile because it has obstretics and gynecology clientele.

D5.1.2 Lowndes County Rural

Geographic Characteristics

The Black Belt stretches across Alabama from west to east and derives its name from the rich black cotton-growing soil in the region. Lowndes County is one of nine counties in the western part of the Black Belt that is predominantly African American. Lowndes County is located about 30 minutes outside of Montgomery. Hayneville is the county seat and the closest town to Montgomery.

Demographic Characteristics

Although the County's population decreased by about 5 percent between 1980 and 1990, nearby Montgomery's recent growth is spilling over, and Lowndes County has grown modestly since 1990. Its population in 1996 is estimated to be 12,980. Fort Deposit (1,600) and Whitehall (1,000) are the County's largest towns. Hayneville has about 350 to 400 people.

Seventy-six percent of the County's population is African American, 23.5 percent white, and less than 1 percent Hispanic, American Indian, or Asian Pacific Islander. Mosses, a small community located west of Hayneville, has a population that is nearly 100 percent African American, except for a few white nuns that run Catholic Services. Under-reporting in the last census may underestimate the County's African-American population.

Economic Characteristics

Unemployment has been a chronic problem for Lowndes County residents, and many people in the labor force must seek work outside the County. Residents work in places like American Apparel (a sewing factory for Army fatigues), Liz Claiborne, the S and C factory, meat packaging and poultry processing plants out of Montgomery, or in various other factories in Montgomery, Selma, or Greenville. The General Electric Company has opened a plant in the County, but most local residents could not meet the skill requirements, and jobs at the plant have gone mainly to people from Montgomery or elsewhere. GE operates its own health center for its employees and their families, so the benefit to the County has been mainly in the form of taxes, rather than direct services. In addition to the manufacturing industry, there are agricultural and some construction jobs in the area.

In 1996, the estimated median household income for Lowndes County is $19,533. In addition, 31.7 percent of all households and 58.6 percent of female-headed households in the county have incomes below the poverty level. Close to 30 percent of the County's residents live in mobile homes.

Social Characteristics

The small rural towns in Lowndes County have little to offer in the way of community services. Mosses, for example, has three or four convenience stores, a couple of juke joints, and a public housing project. In 1987, a community center was built that houses the mayor's office, the city clerk, and the water control clerk. A day care center was located in the community center, but it was closed because residents could not afford it. The public housing project in Mosses, with 48 apartments, was built by the South Central Regional Housing Authority. The other housing project in Lowndes County is in Fort Deposit, in the southern part of the County.

Transportation was reported as a significant problem for many County residents. Twenty percent of the County's households do not own a vehicle. This does not imply that those residents do not have access to a car, but it does shed light onto issues of transportation within and out of Lowndes County. The public transportation system has limited routes and does not run on weekends. It is used mainly for transportation to and from the doctor's office and classes in Montgomery.

Organized recreation, especially for teenagers, is extremely limited in Lowndes County. The County has no public libraries, YMCA, or public swimming pools. Some communities have organized summer softball leagues. The County has one poorly maintained public park. Due to the lack of transportation, teens have difficulty getting around between the different towns. Because of the lack of recreation and transportation, we were told that having sex is one of the main forms of recreation for teens.

Teens in Lowndes County are reported to be very sexually active. We were told that children are having sex between classes at school, in the hallways, in the bathrooms, and on the school bus. The school principals have to walk the halls all day to check for sexual activity on the premises. Young teenage girls are said to be having sex with multiple partners, and it was commonly reported by members of the community that girls as young as thirteen or fourteen are dating men in their twenties. As a result of this high sexual activity, teen pregnancy is a problem in the county. Almost 20 percent of all births are to mothers under age 20. The birth rate in Lowndes County (20.3 per 1,000 residents) is the highest in Alabama (US Bureau of Census 1994a).

Educators and community organization representatives in Lowndes County feel that the teens from this rural area are adopting emblems and behaviors (clothing, gang symbols, speech patterns) that they see and hear from Selma, Montgomery, and other urban places. As in many rural areas in the South, drugs, gangs, and other urban problems have been introduced by children who moved to the North with their families, but were sent back to the South to live with their grandparents when they got into trouble.

Drugs have made inroads into Lowndes County, both from the northern states and because of the County's location near a major drug corridor across the South. The main drug on the street is crack cocaine; however, we were told that marijuana is the second largest cash crop in the County.

Law enforcement resources for controlling drug trafficking are extremely limited. For example, the town of Mosses has no police force, only periodic patrols by the County Sheriff's deputies. Recently, the County has instituted a special tax to pay for a police force there.

Nearly all the students enrolled in Lowndes County public schools are African American. Most white students attend private schools in Montgomery; one nearly all-white private school is located in Lowndesboro. The County has two high schools, one in Mosses and the other in Calhoun. A state-funded vocational school in the County teaches skills like sewing, electrical, and carpentry.

Health Care

As of October 1995, Lowndes County became part of Public Health Area 7. However, it is also one of the six counties, along with Montgomery, that comprise Public Health Area 12 for STD services.

Health Department facilities. The local Health Department clinic is located in Hayneville and is a multiple-service facility. It offers maternity care, WIC, immunizations, and environmental services, as well as STD care. The Public Health Representative (DIS) responsible for Lowndes County is based out of the Specialty Clinic in Montgomery.

Other primary care facilities. The West Alabama Health Services (WAHS) center in Hayneville is a satellite of WAHS, based in Eutaw, Alabama. It is a federally funded community health center and offers full medical services including primary care, physicals for Headstart and school athletes, Medicaid screenings, WIC, immunizations, elderly adult day care, and dental services on a sliding-fee scale. Currently WAHS has one physician, two LPNs, three nurses aides, one full-time and one part-time dentist, two dental assistants, and support staff. In the near future, another physician will be hired. Though this clinic encourages appointments, walk-ins are still welcomed. WAHS sees between 25 and 50 patients daily.

To improve access in the County, WAHS has established one school-based health center in Fort Deposit and has plans to start another on the other end of the county in Whitehall. The school-based health center, funded by the Kellogg Foundation through the School of Nursing at Auburn University-Montgomery, serves students and teachers during the day and the general community from 2 to 5 pm. There are plans to establish a church-based health center with an RN in the near future as well.

Four Rivers Health Clinic, also located in Hayneville, is operated by the Four Rivers Hospital of Selma. The clinic is operated by a nurse practitioner and has a physician from Selma who sees patients one day a week. The only private physician in the county is located in Fort Deposit and sees patients from many of the surrounding counties in addition to Lowndes County.

STD treatment facilities. Although most people in the County would reportedly prefer to go to West Alabama Health Services for general health care, the Health Department is often the choice for STD treatment. However, because Lowndes County is relatively small, and people know each other, many people prefer to go to the Health Department in neighboring Butler County, to Selma, or to Lister Hill Health Center or Primary Health Care Center in Montgomery for STD treatment. This is in part because of concerns about confidentiality at the local Health Department, but also just because of embarrassment due to the fact that staff there may be friends or neighbors. It was reported that truck drivers from out of state often come into the Health Department or rural health clinics with symptoms of syphilis.

D5.2 Key Assessment Issues

D5.2.1 Who is at greatest risk of acquiring/transmitting syphilis

The factors thought to contribute to heightened risk of syphilis infection were very similar in Montgomery and Lowndes Counties. The risk factors associated with syphilis were more clearly distinguished from other STDs by health care providers and Health Department staff than by representatives from community-based organizations, social service agencies, and the general community. However, health care providers did not distinguish between who seeks treatment and who is at greatest risk of becoming infected with syphilis.

Syphilis is not the most prevalent sexually transmitted disease in either the urban or the rural site. Clinics across Montgomery reported seeing more cases of gonorrhea and chlamydia than syphilis. In Lowndes County, in addition to observing more cases of gonorrhea and chlamydia than syphilis, health care providers also reported numerous cases of herpes and trichomoniasis. STD program staff and health care providers indicated that the main change over time in who is at risk for syphilis and other STDs is a decrease in the ages of those infected.

Reported cases of early syphilis in both sites most often involve low-income African Americans. Some individuals (both inside and outside of the Health Department) feel that morbidity statistics reflect some bias, however, because they believe that many white residents turn to private physicians, rather than to public health clinics. Alabama has a dual reporting system, requiring both serology laboratories and treating physicians to notify the Health Department of positive syphilis cases. It is suspected, however, that some private physicians simply treat the patient with antibiotics and diagnose something more general, such as urinary tract infection, thus avoiding the reporting requirements.

Core transmitter was not a term used by people in the Health Department or anywhere else in Montgomery or Lowndes Counties. Many responded that they would use terms like those at highest risk or target group instead. The term cluster was used to describe an example of four reported cases of syphilis (one male and three females) in a two-week period in a housing project in Montgomery.

Below we discuss risk factors identified by respondents, first in the urban, then in the rural site.

Montgomery County Urban

When asked to characterize who is at greatest risk for becoming infected, respondents in Montgomery offered differing opinions.

Gender, race, socioeconomic status. Many respondents thought that drug users, teens, and African Americans in low-income areas are at the highest risk of contracting syphilis. However, a small number suggested a more generalized pattern, with all individuals age 15 through 35, regardless of racial, gender, or socioeconomic status. This difference in opinion may be related to how closely the respondent works with STDs, especially how fine a distinction one makes between syphilis and other STDs.

Age. Respondents lumping all STDs together were likely to mention teens more often than those speaking specifically of syphilis. Community-based organization representatives who work with youth generally believe that the risk for syphilis and other STDs is associated with the limited availability of organized recreational activities. This lack of recreation is viewed as leading to increased sexual activity among young people. Youth workers also point to an outlook of invincibility among teens, a feeling that it wont happen to me. Again, it is unclear whether respondents who mentioned teens as being at risk were making a distinction between syphilis and other STDs. For those who do make that distinction, teens are thought to be more likely to contract gonorrhea, with syphilis more prevalent in an older age group.

We were told by STD program staff (who did distinguish among STDs) that people treated in the urban setting for syphilis infections are usually in their mid-20s to late 30s, slightly older than those being treated for gonorrhea and chlamydia. However, in terms of the connection with crack cocaine, the user population is said to be getting younger, and this mirrors the trend that the average age for those treated for syphilis is also decreasing.

Substance abuse. Those we interviewed in Montgomery generally see a strong connection between drug use and risk for syphilis. The drugs of choice in the area are alcohol, crack cocaine, and marijuana. Crack users, in particular, are said to do whatever they need to do to get their drugs, including trading sex for drugs or for drug money. The local term for women who trade sex for crack is strawberries.

One local medical researcher reported that if a woman tests positive for crack, the chances are one in four that she will be positive for syphilis. Syphilis cases observed by hospital infection control specialists are usually associated with admissions for overdose or chronic substance abuse and psychiatric evaluation. Corrections inmates, often incarcerated for drug-related offenses, represent another reservoir of infection. An outbreak of 80 cases of syphilis in Limestone Prison, near Huntsville, was reported in 1995. Despite this evident association between crack use and syphilis, we were told that in testing for syphilis and HIV at local drug treatment facilities, the Health Department has seen only one case of HIV and no syphilis in the past year.

Commercial sex work versus trading sex for drugs. Public Health Representatives distinguish professional prostitutes from crack users trading sex for drugs, and professional prostitutes were not thought to be at as high risk for syphilis. It makes good business sense for prostitutes to remain disease free, and we were told that some well-known prostitutes in the area go to the Specialty Clinic routinely for checkups.

HIV and other STDs. Public Health Representatives and AIDS prevention outreach workers told us that in the past seven to eight years, an increase in crack cocaine use has created the association with syphilis and HIV, especially among women. They reason that unprotected sex with multiple partners puts women at risk for both diseases. The proportion of latent syphilis that comes into the Specialty Clinic in Montgomery is significant. Clients in this category are usually presenting with another STD, and tests show that they also have an early latent case of syphilis.

Repeat infections. Thirty-five to fifty percent of the patients at the Specialty Clinic have been treated previously, but not always for the same STDs. Repeated gonorrhea and chlamydia infections are reported much more often than repeated syphilis infections. Patients with repeated syphilis infections are thought to make up 25 percent of all persons with repeated STD infections. Repeaters were characterized as typically having lower than average educational achievement (high school or less) and lower socioeconomic status. A handful of dual HIV/syphilis infections have been noted in the past five years. The Public Health Representatives reported that, as policy, when they screen for either HIV or syphilis they ask the clients whether they want to take the test for the other.

Other factors. In Montgomery, Specialty Clinic staff report that the main areas associated with syphilis infection are located west of I-65 and north of I-85, and especially in the public housing projects in this quadrant of the city. In this urban site with two large Air Force bases, however, syphilis does not appear to be associated with the military installations. Truck stops along the southern edge of the city are associated with syphilis transmission.

Lowndes County Rural

HIV and other STDs. In Lowndes County, respondents were much less likely to separate syphilis from other STDs. Therefore, when characterizing who they believed to be at highest risk, respondents often lumped syphilis in with gonorrhea, chlamydia, herpes, and trichomoniasis. For this reason, teenage sexuality was often given as much emphasis as drug usage when discussing risk.

While many respondents recognized that STDs are a problem in the county, syphilis was usually not thought to be as great a problem as gonorrhea. For those who made the distinction, gonorrhea and chlamydia were thought to be more of a problem with teens, while syphilis is seen more in people in their 20s and 30s.

Race. Every person with whom we spoke said that African Americans were more at risk for syphilis than whites. This is not surprising since African Americans make up close to 80 percent of the population in the County.

Age. The high rates of STDs in teens is said to be due to fact that they are very sexually active. In a survey conducted in the county, teens reported that they have had 25 to 250 sexual partners. However, this same survey showed that they have a low level of knowledge and many misconceptions about the causes and signs of HIV and other STDs.

Most respondents in the rural area said it is very common for girls of 14 or 15 years of age to date men in their mid-to late 20s. It was said that the older men are more likely to have money and can offer the girls gifts. We were also told that because some of the single mothers have multiple partners, their daughters emulate this behavior. One respondent mentioned the case of a mother encouraging her teenage daughter to become sexually active in order to clear her skin of acne.

The sexual activity of teens is reflected in the high rates of teen pregnancy in the County. Respondents reported that because the young girls sisters, mothers, aunts, and grandmothers became pregnant in their early teens, teen pregnancy is considered normal and not subject to strong social sanction. It is not uncommon to encounter women in their 30s in Lowndes County who are grandmothers.

Trading sex for drugs. Exchanging sex for drugs is reported to be extensive in rural Alabama, mostly by women aged 18 to 30. This is said to be especially true with crack cocaine. However, the association between syphilis and substance abuse has not been reflected in cases reported by Lowndes County health care providers or Public Health Representatives. Crack use in the area is reported to be very heavy, and the association between crack and syphilis is presumed, even if it cannot be demonstrated.

The Hollywood image of prostitution activities call-girl operations, massage parlors, street strolls does not fit with rural Alabama patterns of sexual partnerships. If Lowndes County residents engage in such activities, they are more likely to do so in Montgomery or other cities. However, we heard reports of a local pattern of women having a series of short-term boyfriends (that is, sexual partners) from whom they receive gifts, money, drugs, or other favors. The health consequences of this relationship pattern may not differ substantially from those associated with what is termed prostitution or commercial sex work in other settings.

Socioeconomic status. While some community members judge the risk of syphilis infections to be concentrated in the public housing projects, others believe that people all over the County are at risk. One physician reported that the only syphilis he has seen in the past year are late latent cases in elderly patients. Syphilis was not perceived as a major problem in the County, while gonorrhea was. One community organization representative expects the incidence of HIV infection to rise soon because of the high rates in the area of unprotected sex with multiple partners.

D5.2.2 What institutions are thought to be most likely to reach those at greatest risk

In Montgomery, and to a lesser extent in Lowndes County, institutions are in place that could potentially be mobilized to reach those thought to be at greatest risk, at least to undertake proximate and intermediate measures.

Schools. In both the urban and rural areas, those to whom we spoke, with few exceptions, felt that the schools are the best institution through which to deliver prevention messages to youth of all ages. In the rural areas especially, because of the lack of organized recreational activities for young people, the schools may be the only place where youth are accessible in group settings. We were told that the Department of Education has HIV coordinators who could deliver STD prevention messages, and school nurses and Public Health Representatives were also mentioned as good possibilities for educating on the signs and symptoms of STDs and how to prevent them.

We were told of recent successes with outside speakers coming into the schools to make presentations concerning sexual health promotion, but what can be discussed is very limited. Schools in rural areas appear to have been more successful at incorporating these messages than urban schools. In both cases, however, mention of condoms is strictly limited, and abstinence is the only sexual choice allowed to be discussed.

Religious institutions. The church is also mentioned among institutions that can effectively reach a large number of people with health promotion messages. In previous years, churches have strongly opposed STD/HIV prevention messages (other than abstinence), but the past two years have seen less resistance, attributable in large part to the work of a minister at the University of Alabama-Birmingham. This minister started an AIDS Care Team, and now other churches are beginning to get involved also. We were told that the churches may be the only place to reach all of the rural residents, with messages being presented in sermons, Sunday school, and personal counseling of parishioners. These same respondents said that this information would first have to be presented to the ministers and other church leaders, possibly through presentations to the ministerial alliance, and that the ministers would need to discuss it with other adults in the congregations before including it in Sunday sermons.

Health care providers. Various health care providers are also regarded as logical channels through which prevention messages could be communicated to at-risk populations, but more could also be done to mobilize providers. Physicians specializing in obstetrics and gynecology were said to be a good group to deliver these messages because they would lend credibility establishing that syphilis and other STDs are truly a major health concern and because they could influence other physicians in the Alabama Medical Association. The Health Department, although it currently follows a traditional system with very little outreach, has the expertise in STDs and could do more to deliver prevention messages in the community. Also, collaborative efforts between the Health Department, local hospitals, drug treatment facilities such as the Chemical Addictions Program, and outreach organizations such as Montgomery AIDS Outreach could be enhanced to include more information on syphilis and other STDs.

Community health centers (CHCs). Another set of important institutions with good access to the at-risk populations, in both the urban and rural areas, are the community health centers (CHC). In Montgomery these include Lister Hill and Montgomery Regional Medical Centers, and West Alabama Health Services in Lowndes County. Statewide, Alabama has 17 CHCs with 52 outreach centers set up to treat indigent residents. These CHCs are said to be better utilized and trusted by African-American and other minority communities than the Health Department. Effective prevention strategies would do well to include the CHCs when trying to reach these groups with proximate and intermediate measures.

Housing authority. In both the urban and rural areas, the Housing Authority is an institution with good access to young single mothers and other residents of the government housing projects. Because of the lack of transportation for these residents, programs offered in the housing projects could reach at-risk individuals not reached by other efforts.

Community-based organizations. Other institutions that should be considered include the Gift of Life Foundation, Planned Parenthood, UAB School of Public Health, Auburn University-Montgomery School of Nursing, and infectious disease programs at the hospitals in the area. In Lowndes County, institutions such as the County Extension Office, the Kellogg Foundation-funded program housed in WAHS, and local volunteers should also be included in proximate and intermediate efforts to prevent and control syphilis and other STDs.

5.2.3 What are the barriers or facilitators to reaching those at greatest risk

Montgomery and Lowndes Counties are home to institutions that could be utilized to implement innovative prevention and control strategies. Some creative and resourceful strategies have been identified locally (as will be discussed in Section D5.3). However, several barriers were identified that would have to be overcome before innovative plans could be implemented.

Local norms about public discourse on sexuality and sexual health. Local norms regarding sexuality included: (1) sexuality as a family matter, (2) prominence of the abstinence message, (3) parents in denial about their children's sexual activity, (4) conservative religious norms, and (5) secular conservatism.

Sexuality as a family matter. Although schools and churches were mentioned in both the urban and rural areas as being the most effective institutions through which to deliver sexual health education and prevention messages, they were also mentioned as the most difficult to access due to what was characterized as a very conservative, Bible-Belt outlook in these institutions. From this viewpoint, issues involving sexuality and sexual health are considered moral issues (not public health issues) that should be dealt with in the family context, rather than in public settings.

It is not clear how adherents of this view propose to deal with issues of sexuality where, for all practical purposes, the family context is absent or dysfunctional. Furthermore, even in well-functioning families, it is a mistake for parents to believe that children contemplating sexual activity will come to the parent for information, as one youth worker told us. It is far more likely that they will just go ahead and have sex with inadequate knowledge about the risks, responsibilities, and means of protection.

Prominence of the abstinence message. The barriers to introducing prevention messages in the schools are twofold. One is that state law prohibits mention of any sexual option other than abstinence in the schools. Second is a fear commonly expressed by parents that sex education in schools is an instructional rather than a preventive course. In this view, if course materials even mention anything but abstinence, they are thought to promote sexual activity among youth.

Health educators are aware of these views and strive to combat them. One health educator to whom we spoke said, I am not an advocate for teenage sexuality. I don't think many of them [the youth] are prepared for the responsibilities that come along with being sexually active. Tired of seeing kids infected with HIV and other STDs, this respondent while acknowledging that abstinence is the only 100% sure way to prevent these diseases nevertheless stated that if the youth are going to be sexually active they at least should know how to protect themselves.

Parents in denial about their children's could be sexual activity. Most parents reportedly believe their children are not involved in any sexual activity and so do not need information about reducing their risk of pregnancy or sexually transmitted infection. Similarly, as one of our respondents reported, the majority of the people in Montgomery would say that they do not believe in sex outside of marriage. These outward expressions of belief, however, would be contradicted by the high rates of STDs and pregnancy among teens and unmarried women.

Conservative religious norms. Similar barriers face church-based health promotion programs. We were told that churches do well with issues that have very little gray area, which is not the case with sexuality and sexual health. Therefore, churches are not open to messages about protected sex and disease prevention unless they are delivered solely within the context of abstinence.

Montgomery reportedly has few progressive churches, with most of them ... on the far edge of the right side. One respondent said that getting sex education into churches in Montgomery would literally be like trying to walk through a closed door. Like the schools, church leaders believe that discussion of anything but abstinence only serves to promote sex.

Secular conservatism. The reluctance to discuss issues of sexuality, which is said to be based on the influence of religion, can also be seen in the secular arena. Although many of those to whom we spoke said that television would be a very effective medium through which to reach teens, the conservative nature of the community prohibits mention of condoms on television.

Any changes in the prevailing local perspectives about how to discuss sexual issues appropriately in public will not come quickly. Health educators find it very difficult, if not impossible, to teach people about how sexually transmitted diseases are spread and how to prevent them when they cannot publicly mention sex or condoms. As noted earlier, however, local residents, especially in the rural African-American communities, are more receptive to frank discussions than are the political and religious leaders who shape state law and public policy.

This suggests to us that efforts to encourage more open discussions of sexual matters cannot be completely abandoned. Health educators may find it productive to use their personal relationships with pastors, school officials, and community leaders to achieve flexibility within the societal limits on discussion of these important matters. Education of trusted community members outside the realms of political and religious power, such as with the natural helper model, may be another good way to approach the limits on discussions of sexual health.

Barriers to access and utilization of policy and training in Health Departments. Barriers to access and utilization included: (1) the issue of mistrust, (2) programmatic funding issues, (3) the medical model, (4) excessive paperwork, and (5) resource availability.

The issue of mistrust. A representative from the STD program staff said that people in the outlying counties are often not receptive to the Health Department in their locations. This is due to perceived breaches of confidentiality and a feeling by patients that they were not treated humanely by Health Department staff. The Health Department's own work on customer satisfaction suggests that public health nurses feel so over-worked and under-appreciated that they become cynical, judgmental, and punitive.

Issues of confidentiality are somewhat different between the urban and rural areas. In Montgomery, since the Specialty Clinic is solely for the care of STDs, patients are concerned that the minute they step in the door everybody knows why they are there. For this reason, many prefer to go to Lister Hill or another multi-purpose facility. In the rural areas, however, we were told that people do not like the fact that the Health Department is multi-purpose. We were told they are concerned that friends or neighbors who are at the clinic for other services will see them and know they have an STD.

Programmatic funding issues. Some programmatic funding issues in the Health Department are also said to interfere with effective STD treatment. For example, we were told that if a woman goes to the Health Department's maternity clinic and is diagnosed with an STD, she will be sent to the Specialty Clinic for STD treatment. The Specialty Clinic cannot treat that woman, however, because she is pregnant. Often that patient will then be sent to the ER of the Day for treatment of the STD. A more effective, patient-centered treatment approach would require a policy change in the Health Department.

The medical model. Another barrier to effective prevention and treatment is the Health Department's heavy emphasis on a medical model of diagnosis, treatment, contact tracing, and surveillance, without significant attention paid to the complex behavioral and institutional elements that are considered outside the Health Department's domain. The State Health Department in Alabama is run by the State Medical Society, which, in turn, implies that state health policy is dominated by physicians. In practice, we were told, the medical model places greatest emphasis on testing and treatment of patients who come into the Health Department clinic, followed by contact tracing and partner notification by Public Health Representatives. Relatively little emphasis is placed on primary prevention efforts such as outreach or education. This is beginning to change, with the introduction of education efforts by Public Health Representatives, since new administrative staff have taken over in the STD division of the Health Department.

Excessive amount of paperwork. Another barrier to effective prevention and control strategies is the amount of time Public Health Representatives are expected to spend doing paperwork instead of being out in the field finding contacts or providing outreach services. The Montgomery office has only one computer available for all six Public Health Representatives to use for data entry. Representatives must wait each day for their turn to use the computer. The Representatives told us they spend around 15 percent of their time each day just doing paperwork, time that could more productively be spent in the field.

Resource availability. Measures that could alleviate some of these problems, such as hiring a clerk specifically to input data from the Representatives, purchasing additional computers, hiring more Representatives so that more time could be spent on education and outreach, creating a more specialized division of labor among the Representatives, all require supplemental funding. Obtaining adequate funding for STD prevention and control is said to be difficult, however. We were told that funding levels mirror STD rates. Funding increases when rates go up, but when staff are able to bring rates down, funding decreases. In this way, STD staff are never able to get ahead of the game and focus their efforts on preventing future cases of syphilis and other STDs.

D5.3 Innovative Prevention and Control Strategies

The Health Department in Alabama operates a traditional control program, with testing and treatment in the STD clinic and contact tracing and partner notification done by Public Health Representatives. Yet despite the efforts of these and other programs, syphilis and other STDs have not been completely controlled. This may have more to do with restrictions put on programs by conservative local forces and a lack of focus on prevention in a traditional public health model than with the effectiveness of the programs themselves. It has been pointed out, however, that future efforts to deal with the syphilis problem, in order to be effective, should be implemented in collaboration with already existing programs to achieve better access to and trust by the at-risk populations.

Below we first present disucssions of some existing innovative programs (Section D5.3.1), followed by thoughts from our respondents about future programs that might be initiated (Section D5.3.2).

D5.3.1 Existing Innovative Programs

In both Montgomery and Lowndes Counties, we were told of existing innovative programs that address social and health issues, some including STDs. Although not many programs specifically address syphilis, these existing programs are worthy of mention, both because of the work they are doing and because they could serve as effective conduits for further interventions relating to syphilis and other STDs. Multiple foci for these programs are highlighted in italics below.

Programs through government agencies.

DARE is a drug prevention program sponsored by the police department targeted to fifth graders.

The County Extension Service in Lowndes County sponsors an annual health fair in Hayneville that includes STD prevention.

Programs through youth-serving organizations.

School nurses in Montgomery are using Postponing Sexual Involvement, a pregnancy prevention program that enhances empowerment, negotiating skills, and communication skills. They are also using a program called Respect Yourself, which addresses decision-making and goal setting.

Headstart provides medical and dental care for its participants, as well as classes on parenting, child abuse prevention, sewing and other skills, and STD/HIV education.

Pattycakes is a program run by the Alpha Kappa Alpha sorority out of Alabama State University, which offers counseling and services for young teen mothers.

Programs through religious organizations.

First Baptist Church Caring Center provides financial, clothing, and food assistance to needy families. Other programs offered by First Baptist Church include: the MOMS Program, which is a year-long self-help program for single mothers who live on welfare; the Life is a Two-Way Street Program, an improvement program for teenage girls; and midnight basketball programs for teenage boys.

Frazier Methodist Church in Montgomery has a health education program that starts in the second grade.

Programs through other CBOs.

Montgomery AIDS Outreach offers testing, counseling, and case management for HIV/AIDS throughout the Montgomery area. The organization has opened clinics throughout the region and works in collaboration with many existing agencies, such as the Health Department, Chemical Addictions Program, community health centers, and other CBOs.

The Council on Substance Abuse is sponsoring numerous programs in Montgomery, Lowndes County, and around the state, such as a crisis line, education programs, poster programs, as well as parenting programs.

Strategies to Elevate People (STEP) is a city-wide program in Montgomery where First Baptist Church and other churches work along side the Health Department, schools, police department, and community-based organizations to provide tutoring and meals to children in the housing projects and other economically disadvantaged areas.

There are also local community volunteers in Lowndes County who give health education presentations, conduct workshops on STDs, work with the churches and schools, and provide counseling and support to local youth.

Programs through women's organizations.

The HIPPY Program is a program in the housing projects in Montgomery that hires mothers to help other mothers with health and social issues.

Programs through educational institutions.

The School of Nursing at Auburn University-Montgomery is using innovative approaches to health education such as designing an anatomically correct model to show how to use contraceptives. They are also opening and operating school-based clinics in Lowndes County through a program sponsored by the Kellogg Foundation.

The Center for Health Promotion out of the University of Alabama-Birmingham School of Public Health has a project with Jefferson and Wilcox counties as the intervention sites and Lowndes County the control site promoting healthy behaviors in the rural African-American population throughout the life span. The project will promote hygiene behavior in children; child spacing, well-baby and prenatal care among women; and a school-based program for adolescents. It will also focus on cancer prevention and hypertension interventions among adults. The project further looks at sexual risk taking and perceptions of community risk related to STDs. This project includes participation by the local African-American population in all aspects from design through implementation.

D5.3.2 Thoughts for Future Strategies

Thoughts from our respondents on possible future strategies for syphilis prevention and control include: (1) increased public health outreach, (2) increased community education, (3) youth programs, and (4) community-bases activities.

Public Health Outreach

People working in public health mentioned a number of innovative ideas for prevention strategies. One of these ideas is funding full-time street outreach workers who can reinforce prevention messages, provide community service, and educate on what health services are available and how to access them. Other ideas include mass testing campaigns for STDs, mobile vans providing medical services, and extended clinic hours at the local Health Department.

Community-wide Health Education

A common theme among respondents was the need for more widespread education on STDs and other related health issues. Discussion of sex or STDs in schools is very limited, and it was said that parents are not educating the children at home, which helps account for the continuation of high rates of teenage pregnancy and STDs. Youth are said to want the information, but must report to obtaining it from their equally misinformed peers. The consensus is that education needs to be provided in both schools and homes.

We were told by many respondents in both urban and rural areas that youth should receive age-appropriate health and sexuality education in the schools, beginning with basic hygiene in the elementary schools and moving to issues of pregnancy and STD prevention in junior and senior high school. However, it was also agreed that parents and families must be involved if the information is to be incorporated into behaviors. Many respondents suggested educational training courses to provide parents, teachers, and community leaders with appropriate information and ideas on how to present it to youth.

We were told that this education is needed so that those in health care and in the community can begin on the same page, sharing a common knowledge base from which effective prevention efforts can be launched. For those who are not in school and are not parents, prevention messages could be presented through community-based classes; videos presented at grocery and liquor stores; and advertisements on television, radio, and in newspapers.

Youth Programs

Many respondents also mentioned that training in self-esteem and personal efficacy building is needed in combination with health information, to assist young people in making better decisions about activities that could put them at risk for diseases. Young people also need techniques to implement decisions about their sexual activity, such as communication, decision-making, and conflict-resolution skills. Comprehensive programs operating on multiple fronts allow youth not only to understand the consequences of unsafe practices but also to reach and implement sound decisions about their actions and their futures.

Many of those to whom we spoke, especially in the rural areas, said that recreation programs are needed for young people, and that these programs need to be available every day after school, not just occasionally. One respondent from the rural area told us that there is a lot of athletic and artistic talent in the local youth that is not being enhanced. Youth need an ongoing program, but one where attendance is not mandatory. Reliable transportation should be provided to bring youth to and from activities.

Such a program would have to be sold to the young people, who also need to feel they have input into its design. Volunteers would be needed to operate the program, and once established, the program could also be used as a setting for teaching life skills, parenting skills, and sex and health education. The churches could be good locations for this kind of program, but again, ministers and parents would first have to be educated about the problems of teen pregnancy and sexually transmitted diseases.

Other Community-Based Activities

Another idea for increasing knowledge about STDs (currently being implemented for other diseases) is to educate core members of communities to serve as local experts and resources on health issues such as STDs. This decentralized approach, where community leaders become the messengers, is known as the natural helper model and is said to be especially effective in rural minority communities, where trust of the messenger is very important. These local experts can serve as sources of information and skills in the community and can train others.

Further ideas for innovative prevention programs include large health fairs in communities. We were told that these efforts work better when STDs are not presented alone, but rather placed in the context of education, screening, and referral for a broad range of health issues. It was said that health fairs should address blood pressure screening, diabetes care, nutrition education, and first aid, along with STDs. One respondent said that the key is to look at the total person. Informed and trained community leaders (natural helpers) would be excellent conduits for the health and prevention messages at these health fairs.

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