In the Black Belt, disparity has always been part of the landscape. Social scientist Arthur Raper, in his landmark 1936 study of this Deep South region, called it the home of “the richest soil and the poorest people” in the country—and that description holds true today. Running from Virginia to Texas, this is a 200-county stretch of enviable farmland and heart-wrenching poverty, whose predominantly African-American residents have spent more than a century coping with some of the most glaring health and financial disparities in the United States.
Communities in Alabama’s 19 Black Belt counties suffer from rates of infant mortality, HIV/AIDS infection, cardiovascular disease, diabetes, and hypertension that are higher than the rest of the state, as well as greater than normal rates of deaths caused by strokes, heart attacks, and cancer.
This is a sparsely populated region, still rural in character, and underserved in countless ways. The creaky infrastructure cannot support the kind of industrial development that has enriched other rural parts of the state, and the residents share a common heritage of cotton plantations, slavery, and sharecropping. For the most part, they live in small, tight-knit communities where life is centered on church and family. People here tend to be suspicious of outsiders, particularly researchers—and not without cause. In the most egregious example of abuse, government health officials studied the effects of syphilis in hundreds of Macon County residents between 1932 and 1972, deliberately preventing the unwitting subjects from obtaining treatment for their disease.
After decades of neglect, efforts to understand and combat the health disparities of the Black Belt began to take shape in recent years. The region became a magnet for medical and public-health researchers, leading to a steady stream of scientific papers and policy recommendations. Yet residents often saw little result from these efforts.
Changing Minds, Changing Lives
“The problem is that at one time everyone wanted to study the Black Belt, but do nothing as far as programs that would affect people’s lives,” says Donald Stone, a lifelong Black Belt resident. “That was a sore point.”
Visiting health-care workers tried to help, offering treatments and information on lifestyle changes that could sharply decrease residents’ risk of falling victim to disease. But they could reach only a few of the hundreds of far-flung communities scattered across thousands of square miles, and their advice often fell on deaf ears.
Starting in the mid-1990s, researchers in UAB’s schools of medicine and public health set to work on a new, community-based approach. Professional health experts began to train trusted local leaders, equipping them with information and resources that they could pass along to residents directly. This community health advisor (CHA) model, already a proven success in programs around the world, also worked well in the Black Belt.
“UAB involved local people to correct problems, rather than people coming in here for a hot moment and leaving,” says Stone. He has been an active participant in two Black Belt projects initiated in the 1990s by UAB’s School of Public Health and School of Medicine.
Well-connected, community-minded individuals like Stone are the cornerstone of these efforts. He has a long history of social involvement and is the son of an African Methodist Episcopal clergyman and grandson of the founder of the Snowhill Institute, which was modeled on the Tuskegee Institute.
Stone became involved with UAB’s efforts in 1995, when Vee Stalker, Black Belt liaison for the School of Public Health’s Center for the Study of Community Health, began recruiting CHAs for a major new project. The mission, funded by the Centers for Disease Control and Prevention, was to reduce cardiovascular disease, high blood pressure, and diabetes among the African-American population through long-term lifestyle changes. The project targeted three major health culprits: diet, exercise, and tobacco.
To find candidates for CHA training, Stalker enlisted the help of Ethel Wilson, at the time an assistant to Sheryl Threadgill-Matthews, chief of the state human resources office in Camden, the Wilcox County seat. The two women and Donald Stone were named to the Community Participation Board formed later in the project.
“We began,” Stalker recalls, “by asking one person to identify two people who might be interested in becoming CHAs. Then we asked each of them to identify two more, until we had about 20.”
Old Ways, New Attitudes
Armed with information, the advisors set out to create change. Prevalent cooking methods in the Black Belt produced dishes high in fat and salt. Food was fried in lard, vegetables were cooked with salt-pork or ham, and fresh fruit and vegetables weren’t available in most small towns. It was rare to see anyone walking or running for exercise, but common to see smokers. Even though most people knew about the dangers of tobacco, they were not aware of the harm done by fat and salt, or that traditional recipes could be changed to produce food that is both healthy and tasty.
Twelve years later, the CHA program has made noticeable changes. There are two
exercise programs in Camden, and “you see people out walking,” says Stalker. A long hiking trail in nearby Pine Apple was built by a coalition of black and white residents, with help from elected officials who provided manpower and equipment to do grading and from many volunteers, who donated their labor and even equipment. The funding included a $25,000 grant from the Robert Wood Johnson Foundation and an undisclosed donation by a local resident.
Eating habits have also changed as people have learned how food can affect their health, Stalker notes. They use vegetable oil instead of lard and cook vegetables with a turkey wing instead of pork. Fresh fruit and vegetables, which were hard to come by if you didn’t grow them yourself, are now available during the week at farmers markets established in three Wilcox County towns—which even accept coupons from people with meager incomes. The CHAs have also been instrumental in producing a cookbook featuring soul food recipes that have been changed to be healthy and still taste good.
The Next Step
The success of the School of Public Health’s initial 10-year CHA program led organizers to see if its behavioral-intervention model could be expanded by giving local volunteers the same training but less hands-on assistance.
Flying Sparks, as the program is known, has expanded the local volunteer network from the original four-county area to include three more Black Belt counties. Volunteers are trained as community health coordinators and taught to find and train future generations of volunteer workers without the assistance of UAB professionals like Vee Stalker and others who assisted the first cadre.
Each coordinator is given a toolbox containing materials, including manuals and a video, offering step-by-step instructions on how to recruit and teach new CHAs to promote exercise, healthy eating habits, and smoking cessation. Training manuals include specific programs to recommend, including the effective Meatless Monday effort that some communities adopted during the first CHA project.
To test how the initial training of the coordinators affects their success, CHAs in four communities were randomly chosen to receive intensive training, while the rest received brief training and could phone or e-mail UAB professionals for follow-up help. The initial wave of coordinators completed their training last fall and are now working to spread healthy habits in Wilcox, Lowndes, Marengo, Perry, Sumter, Monroe, and Dallas counties.
Some health problems, of course, cannot be prevented by lifestyle changes alone, but information is still vital. In an effort to combat the high rates of breast and cervical cancer among African-American women in the Black Belt, UAB’s Minority Health and Research Center (MHRC) recruited an army of CHAs some 800 strong.
These knowledge warriors formed the backbone of two landmark MHRC projects. The Deep South Network (DSN) for Cancer Control, funded by the National Cancer Institute, is working to eliminate disparities in cancer deaths between whites and African Americans in Alabama’s Black Belt and the Mississippi Delta region, as well as in two urban areas: Jefferson County, Alabama, and Hattiesburg, Mississippi. Local CHAs are trained to help spread cancer awareness information in their communities and to encourage African-American participation in clinical trials.
Meanwhile, the REACH 2010 project (Racial and Ethnic Approaches to Community Health by the year 2010), funded mainly by the Centers for Disease Control and Prevention, targets communities in Alabama’s Black Belt. It has already recorded significant success in reducing disparities between the rates of mammography among African-American and white women in the targeted counties, says Mona Fouad, M.D., who directs both the MHRC and the REACH project.
In 1998, the year before REACH 2010 was launched, the gap between African-American and white women getting mammograms was 17 percent, Fouad notes. By 2006, the disparity had dropped to 6 percent. And in one targeted county, she says, it has actually been reversed.
To achieve these results, the CHAs have contacted at least 2,000 African-American women. They keep records of each contact and send the women reminders of when their next mammogram is due. Many times interaction is one on one, but CHAs have also held fashion shows and other community events to draw an audience.
Navigating the System
As their mammogram drive succeeded, the CHAs had to address a more complicated, life-threatening challenge: how to help the women whose tests were positive for cancer.
“Our volunteers were getting calls from women who didn’t know what to do,” Fouad says. With a grant from the Avon Foundation, 30 CHAs received additional training to become Patient Navigators, learning how to find resources to meet the cancer patients’ needs, which were urgent and often numerous.
Transportation is a continuing challenge. The nearest treatment centers are in Selma and Montgomery, and there isn’t any public transportation in the Black Belt. Some churches and other civic organizations have stepped in, joined by individuals who volunteered to ferry patients back and forth in their personal vehicles.
Some women also have to be convinced that treatment won’t mean financial ruin. “It’s very easy for a woman who gets sick to become homeless in the Black Belt,” Fouad says. Some simply don’t know that Medicaid can cover their medical costs, like the blind woman living on a $300-per-month disability check who told a CHA she couldn’t afford to pay for care. The volunteer helped her get Medicaid coverage and arranged for her to undergo treatment.
Fouad says the CHAs were able to find resources to satisfy a host of needs, including day care, meals for women too sick to cook, money for overdue power bills and other unpaid debts, and free legal assistance to deal with creditor threats. Now there are resource guides compiled by CHAs for each community.
The Patient Navigation project has succeeded in getting 95 percent of the women to keep their appointments for treatment, and the CHAs deserve a big share of the credit, emphasizes Fouad. “We’ve gone way beyond medicine here,” she says.
As the health-care system becomes more complicated and sophisticated, the role for local community health leaders will assume a greater prominence, adds Max Michael, M.D., dean of the School of Public Health and director of the Center for the Study of Community Health. “We are learning each day about the importance of health promotion and disease prevention in assuring individual and community health,” he notes. “The CHA model offers promise and hope for communities often isolated from the traditional health-care system.”
It Takes a Villager
The Black Belt Institute was founded three years ago as a project of the School of Public Health’s Center for Health Promotion, which recently merged with the Center for Community Health Resources and was renamed the Center for the Study of Community Health.
“The idea was to hold a symposium that focused on different health topics each year,” says Max Michael, M.D., dean of the School of Public Health and director of the center. “The concept is really neat. Public-health professionals at the center work with community health advisors (CHAs) to identify health issues impacting their communities, such as obesity, which is this year’s topic.
“The CHAs then come together at the one-day Institute, which is held at the University of West Alabama (UWA), to create methods and strategies for tackling the issue within their respective communities. For instance, in targeting obesity the CHAs might stress the need for regular exercise, dietary changes—such as eliminating fried foods and sweets—and pointing out to parents that they have a big influence on what kids eat.”
Michael says the gathering is an extraordinary experience. “UWA has been most kind in letting us have this venue, which is perfect, as it’s central to where many CHAs live. Part of the measure of the success of the institute is that people come back, which says to me that the information, the discussion, and the dialogue are useful.”
From the Ground Up
Stalker says public-health professionals and community health advisors recognize the need to start at the community level rather than with professionals to effectively promote healthy behaviors. In its third year, the institute now has 320 people on the mailing list to attend.
“It has been amazing that, just by word of mouth, people call us asking to be put on the list to receive an invitation,” Stalker says. “It’s gratifying that people have been so responsive and that we can see the sharing of successful ideas that CHAs can take back to their own communities. CHAs need nourishment and encouragement themselves in order to be effective.”