Seattle's global health powerhouses turn their attention to south King County

Morocco was the last place that Asma Bulale expected to spend her summer vacation when she started medical school. But several years ago, the 31-year-old former Somali medical student at the University of Washington decided to switch from cardiology to public health and become an AmeriCorps volunteer.

Last summer, Bulale began working with rural community-based health organizations in Morocco. A native of Mogadishu in northern Somalia, she visited health clinics in villages in dire need of basic health education. Eventually Bulale and her fellow volunteers set up clinics to do screenings for general health. That experience proved to be life changing.

Now Bulale is a community health promoter in another marginalized, low-income community where access to affordable health care is problematic: south King County. At first glance, applying the lessons learned from developing nations in North Africa, Asia, or Central America to residents in Tukwila and SeaTac might seem a stretch. But Bulale has learned otherwise.

South King County is home to a growing melting pot of newly-arrived refugees and immigrants who speak well over a hundred different languages, from Somali, Eritrean, Ethiopian [Amharic], and Bhutanese to Spanish, Arabic and Turkish. According to the 2010 Census, Tukwila now has the most diverse school district in the nation.

Besides the language barrier, immigrants in Tukwila and SeaTac face other formidable hurdles navigating the American health care system. Foremost among them is a basic distrust of western medicine. "They're very set in their ways because of their culture and religious beliefs," said Bulale, who is fluent in Somali and Arabic herself.

The nation's center for global health, Seattle seems the logical place for the development of new approaches to providing health care in under-resourced communities. Besides the Bill and Melinda Gates Foundation, organizations such as PATH, the Fred Hutchinson Cancer Research Institute, Seattle BioMed, Seattle Children's, Infectious Disease Research Institute, the University of Washington, and Washington State University are engaged in groundbreaking research in the kinds of medical intervention that Bulale and other community health promoters are delivering.

Three years ago, Dan Dixon and Dr. Rod Hochman set about looking for new solutions to the health-care needs of low-income residents in Washington State. Dixon, vice president for external affairs at Swedish Health Services, and Hochman, CEO at Swedish, hosted a gathering of 20 global health leaders in the region. That meeting eventually spawned the Global to Local Healthcare Initiative [G2L].

A collaborative partnership of the Washington Global Health Alliance, Seattle and King County Public Health, HealthPoint, Swedish, and the cities of SeaTac and Tukwila, the G2L project seeks to improve health outcomes and reduce health disparities in the target, underserved South King County communities of Tukwila and SeaTac through the use of proven global health strategies.

In November 2010, the project commissioned PATH, a Seattle-based global health organization, to do a landscape analysis, which confirmed many of the suspicions of local health experts. Along with its significant racial, linguistic, and sociocultural diversity, high rates of poverty, and poor health are the area's defining characteristics.

"We discovered in our assessment that SeaTac and Tukwila have large pockets of poverty with a health index nearly identical to Nairobi, Kenya," said Dixon. "We were shocked, and sobered. It seems patently unacceptable." The survey also revealed longstanding economic disparities between haves and have-nots.

Those findings are borne out by recent demographic surveys of south King County and Tukwila-SeaTac. Compared with King County, the health indicators in those two communities are among the nation's worst: higher incidences of chronic disease, increased infant mortality, cardiovascular disease, diabetes, asthma, and tuberculosis. A large proportion of the non-English-speaking residents are uninsured, and lack money and access to affordable health care. Local stores are inaccessible to transit and even lack fresh produce.

"While some places in King County are the healthiest in the nation, some of the least healthy are just a bike ride away," said Dr. David Fleming, director and health officer at Seattle King County Public Health. The former director of the Gates Foundation's Global Health Strategies Program is optimistic however.

"We are lucky to live here because we have the most expertise in global health in the world, second to Geneva, Switzerland. While we have to cope with the challenges of a resource-constrained area, there are good people here with the talent to work on those same problems," Fleming said.

Gaetano Borriello's students in the University of Washington's Department of Computer Science and Engineering are just a few of those good people. In the spring of 2011, several of Borriello's undergraduates, working with other students in the department's Human Centered Design program, designed prototypes for new mobile devices to help the G2L project meet one of its objectives: helping south King County residents find cheap, affordable interpreters.

For most immigrants, one of the major hurdles to finding the right social services for promoting health is overcoming the language barrier. "Commercial interpretation services do this, but they're very expensive and require extensive infrastructure," Borriello explained. "So our students devised a way of getting interpreters for all the immigrants in the target populations."

With the assistance of T-Mobile, which plans to deliver 1,000 mobile phones, Borriello's students designed an Android system using a cellular network rather than multiple land lines and switchboards. If Spanish-speaking residents in Tukwila need an interpreter, for example, they can simply send a text message to a central number that triggers an interpretation request to a network of volunteer interpreters. Within minutes, an interpreter calls back the individual and schedules an appointment.

"We don't have to worry about capacity, because it just uses the cellular network and runs cheaply," Boriello said. "We're trying to help community organizations that don't have big money." The G2L project is piloting the new mobile communications system and plans to include additional languages later this year.

Researchers are also now at work developing new applications for diabetes education. Both communities' soaring diabetes rates eclipse those of the rest of King County, said Dixon. "If you're poor and ninety percent of your monthly wages go to shelter for your family, you don't have much money left for food. We're developing a robust diabetes education program so we can monitor and triage patients and prepare for the tidal wave."

Because diabetes is the most prevalent issue, community health promoters like Bulale encourage residents to get professional health screenings. Once the screening is done, Bulale also leads diabetes support groups. Diet is often a major concern. "There are a lot of Somalis in Tukwila and SeaTac. I [as a Somali] come from a nomadic society, so our traditional food consists mainly of meat and milk," she said. "We try to incorporate more vegetables in their diet and integrate traditional with healthy foods."

While traditional health care approaches focus on one problem at a time, the Global to Local Healthcare Initiative strives for a broader strategy. "We want a holistic approach that links health care delivery with economic development, housing and transportation, access to fresh food, and improving health education," said Lisa Cohen, executive director for the Washington Global Health Alliance.

In the economically-struggling communities of SeaTac and Tukwila, the link between health and economic development is not lost on G2L project planners. Many residents earn minimum wages. "If the cheapest rents for apartments average $700 month, that leaves $200 for other needs," said Fleming. "Consequently, health will drop down low on their list of priorities. From a needs standpoint, lack of money to seek medical care is a primary problem."

Like global health programs in developing countries, the G2L project supports community-driven health care strategies. Community empowerment is central, said Cohen. "We had a number of meetings with SeaTac and Tukwila residents, and at first, they were very suspicious of our motives. It took a good year to develop trust." In the end, it became clear that the traditional approach of parachuting into the community with a clinic, nurses and doctors was not what was needed.

Deploying community health promoters like Asma Bulale has been more effective and less cost prohibitive, Cohen said. "They can visit people in their homes, train a member of the community who speaks the language, and talk to people about our program."

Still, using community health promoters and employing technology to transform community health practices are just a few of the broader arsenal of global health strategies that the project is using to link primary health care with public health services.

G2L planners organized community discussions to provide a venue for SeaTac and Tukwila residents to identify top-priority health issues and share their vision for a healthy community. Through a JPMorgan Chase Foundation grant, the G2L project is creating a leadership development program to identify and mentor community leaders.

Building on the Digital Green initiative in India, the group is orchestrating a social marketing campaign to encourage healthy living. Bulale and other health promoters will support community residents to make videos that demonstrate how they are living healthy lives despite the challenges they and their neighbors face.

HealthPoint, a nonprofit in SeaTac that provides home health care services to more than 60,000 King County residents, will pilot a new video remote interpretation service or video chat. "We are all about health equity," said HealthPoint CEO Thomas Trompeter. "We're not going to achieve it simply by providing services in clinics." The G2L project also plans to establish a medical interpreter training program at Highline Community College and to host community health screenings, which can help reduce the risk of chronic disease.

A text-messaging program developed through the partnership sends daily messages about healthy eating and promotes healthy behavior change. The Refugee Women's Alliance is using the phones to support ESL [English as a Second Language] classes.

Since its debut at the Swedish 2010 Healthcare Symposium, the Global to Local Healthcare Initiative has received a significant boost from a $1 million grant from Swedish and funding from the Seattle-King County Public Health Workforce Development Council. Project partners like Swedish hope the new global initiative can be scaled up elsewhere in the country.

"Our long-term goal is that this initiative will be eminently replicable in Cleveland, the Bronx, and other locales," said Dixon. "One of the things that drives this collaborative is the belief that this is not a philanthropic venture. We can do well by truly doing good. Swedish doesn't have clinics in the community, but it is interested in finding ways to provide care without having them come to an emergency room."

The G2L partnering organizations all agree that collaboration is of critical importance. "We're not going to have enough resources to address these systemic issues of bad health and economic disparities. We can only tackle them by working together," Dixon said.

"The Global to Local Healthcare Initiative shows the importance of creating strong public-private partnerships to create innovative tools to improve the health of our residents and neighbors," adds Tukwila City Councilmember De'Sean Quinn. "This program really addresses the challenges we face head on, breaking down barriers and challenges every day."

For Asma Bulale, applying global health solutions to local communities also affords more intangible rewards. "Personally, I like seeing change. At the first community café we had, you could see how strong the community is and how much they want change. When I see things actually happen before my eyes, that's when I see it as good work."

Collin Tong is a freelance journalist and Seattle-based stringer for the New York Times.