In a sadly still unequal U.S., parasites flourish and rural moms can’t get care

hookworms-300x201It can be too easy to forget the unfortunate, inequitable legacy of the Old South, especially how racist Dixie created stark racial health disparities. But sometimes a foreigner’s jab in the ribs can remind us how making America great again could mean tending much better to our collective p’s and q’s in public health, especially so poor, rural people of color don’t get tropical parasite infections and they do get reasonable access to critical maternal care.

The Guardian, a British news outlet, has pointed out that new, published research shows a disgusting resurgence in Americans, notably in Alabama, testing positive for hookworms, a debilitating “gastrointestinal parasite that was thought to have been eradicated from the U.S. decades ago.”

As the Guardian reports:

The parasite, better known as hookworm, enters the body through the skin, usually through the soles of bare feet, and travels around the body until it attaches itself to the small intestine where it proceeds to suck the blood of its host. Over months or years, it causes iron deficiency and anemia, weight loss, tiredness and impaired mental function, especially in children, helping to trap them into the poverty in which the disease flourishes. Hookworm was rampant in the Deep South of the U.S. in the earlier 20th Century, sapping the energy and educational achievements of both white and black kids and helping to create the stereotype of the lazy and lethargic southern redneck. As public health improved, most experts assumed it had disappeared altogether by the 1980s. But the new study reveals that hookworm not only survives in communities of Americans lacking even basic sanitation, but does so on a breathtaking scale. None of the people included in the research had travelled outside the US, yet parasite exposure was found to be prevalent, as was shockingly inadequate waste treatment.

The Guardian points out that health researchers went to Lowndes County in Alabama to conduct their difficult study among some of the nation’s poorest and black residents. Their hard lives don’t leave them with much money for even basic plumbing, so much of what they have is “open pipe”—a single waste line that runs precariously and insufficiently far from homes and water supplies. This crude sanitation often breaks down and backs up in the area’s shallow, rocky earth, especially during heavy rains.

Residents are reluctant to complain or to seek help because local and state authorities have prosecuted Alabamans with open-piping systems. So, residents, instead, make do, including with hookworm infestations and other scourges, such as infestations of disease-carrying mosquitoes.

Researchers struggled to get residents to cooperate with their public health study, due, too, to the stigma of their poverty and illness. Residents told the Guardian they are mystified why, in a nation of such wealth and philanthropists like Bill Gates who care for so many globally, their plight has put them back into terrible conditions that their grandparents struggled with and suffered to throw off, including in the Civil Rights Movement of the ‘60s.

Meantime, for rural residents, in general, and for African Americans specifically, matters are no better when it comes to maternal health services. University of Minnesota researchers recently examined obstetric services in the nation’s 1,984 rural counties over a 10-year period.

As Pro Publica, the Pulitzer Prize-winning investigative site, has reported on the experts’ findings:

In 2004, 45 percent of rural counties had no hospitals with obstetric services; by 2014, that figure had jumped to 54 percent. The decline was greatest in heavily black counties and in states with the strictest eligibility rules for Medicaid. The decrease in services has enormous implications for women and families, says Katy B. Kozhimannil, an associate professor in health policy who directs the Minnesota center’s research efforts. Rural areas have higher rates of chronic conditions that make pregnancy more challenging, higher rates of childbirth-related hemorrhages — and higher rates of maternal and infant deaths. And because rural counties tend to be poorer, any efforts to revamp or slash Medicaid could hit rural mothers especially hard.

Pro Publica, which has focused some of its recent reporting on why the United States has one of the highest maternal mortality rates in the developing world, especially for black women, interviewed one of the Minnesota researchers in depth. She pointed out that the current efforts to repeal and replace the Affordable Care Act (aka Obamacare) and to roll back its expansion of the Medicaid program for the poor will worsen the disappearance of maternal services in rural America.

That, of course, will increase expectant moms’ burdens in far flung parts of the country, where transportation and logistics issues already loom large as they try to figure how to keep themselves and their babies healthy.

For black babies, the news persists in being poor: As researchers at McGill University in Canada found while sifting through data from the federal Centers for Disease Control and Prevention, “The sustained progress in reducing infant mortality among black infants since 2005 has stalled in the past few years. This has led to increases in the absolute inequality in infant mortality between black and white infants during the past three years.”

That’s unacceptable. In my practice, I see not only the major harms that patients suffer while seeking medical services but also the significant economic hardship and inequities they encounter in accessing what may become complex, long-term, and vital medical treatment. The recent political acrimony over the ACA demonstrated that partisans are too willing to divide our country and they’re too willing to accept racial, economic, geographic, and gender disparities in the medical services. It’s hard to imagine that this great country, which has made so much social progress, can go backward and casually accept the separate and unequal, especially in an area as critical as medical care. But, then, again, here in Washington, D.C., we’re watching as regulators shut the obstetrics service, apparently due to poor and risky care, of a major public hospital that serves the district’s poor and minority communities.

We may have come far, but not far enough, and we have much to overcome, still.

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