Worlds Apart

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Part 1: Where we live can determine how long we live 

Part 2: St. Louis struggles with its promise to care for the poor

Part 3: Mothers find state WIC rules create obstacles to getting nutritious foods

Part 4: Co-op is oasis in urban food desert

Part 5: City parks and sidewalks play a role in health disparities

Part 6: BODDY building: Washington University program helps St. Louis residents shed pounds, regain health

Part 7: St. Louis gets the lead out

Part 8: Rescuing Larry: Public health workers help a worried mom save her child from lead poisoning

Part 9: St. Louis University pioneers new approach to preventing lead poisoning

Part 10: Race and place matters when it comes to diabetes

Part 11: Public health workers place their bets on diabetes education

Part 12: Program for treating teens with STDs hits the spot

Part 13: Street smarts and training aid in the battle against sexually transmitted diseases

Part 14: New sexual health programs for girls in foster care

Part 15: Safer neighborhoods can lead to leaner bodies

Part 16: A 'Healthy Start' for infants can make a huge difference

Part 17: 'Outreach moms' forge a bond with at-risk mothers

Part 18: Doctor-patient communication gap can cost lives and increase health-care costs

Part 19: How low can you go? Missouri falls to 39th in health rankings

Part One: Where we live can determine how long we live

Larry Chavis, George Banks, Tracy Blue and Carolyn Dickerson are from different neighborhoods in north St. Louis, but all four have at least one thing in common. They have health problems that are largely preventable and far more prevalent among African Americans than the rest of the city's population.

Coping with lead poisoning has turned Larry into an unusually quiet 4-year-old. His mother hopes treatment will help him ward off any long-term consequences.

Banks, meanwhile, is trying to beat a different set of health-related odds stemming from his battle against diabetes as he approaches old age.

Blue is an energetic college-educated woman who uses bursts of laughter and self-deprecating humor to cope with diabetes, weight problems and occasional bouts of depression.

And Dickerson is an example of the city's premature birth problem. But hers is a success story, thanks to the intervention of a highly regarded maternal and child health program. It gave her the means to rise from poverty and become self-sufficient for herself and her child, Isaac, now 4. Isaac had faced a high risk of being among the 12 out of 1,000 city infants who don't make it to their first birthday.

Larry Chavis, George Banks, Tracy Blue and Carolyn Dickerson are among the St. Louisans featured in this Beacon series about how and why some health and social conditions afflict African Americans in certain zip codes at a much higher rate than whites. They are known as health disparities or inequities. And, for the most part, they have been accepted as perplexing but unsolvable facts of black and white life in St. Louis and the nation.

Public health as prevention

Until now, that is. One aim of the new health-reform law is to reverse the notion that health disparities are inexplicable and inevitable. The new law is expected to address the issue in part by re-energizing the public health movement.

While medical doctors treat disease, public health workers identify trends, explain why people get sick and address conditions that trigger illnesses. Public health work includes screening children for lead poisoning, offering nutrition programs for diabetics, and setting up sex education classes to try to prevent the spread of sexually transmitted diseases, or STDs. Over the years, this work has faltered from a lack of manpower and money. That has allowed some diseases to move way beyond the prevention stage. Traditional medicine has been left to fill the void with a case-by-case approach to treating disease. It as if we had responded to the massive BP oil spill by dealing with one oil-soaked fish at a time.

Still, the news in some poor St. Louis neighborhoods isn't all bad. Examples include the city Health Department's sustained attack on lead poisoning and a similar effort planned for childhood asthma. Another is the Maternal and Child Health Coalition's push to reduce infant mortality. These challenges have prompted providers to be more imaginative in the ways they view and tackle health problems.

Looking upstream

We can trace the roots of such efforts all the way back to the 19th century and the work of Dr. John Snow. He's credited with looking beyond conventional thinking during a cholera outbreak in London. Snow eventually traced the epidemic to a contaminated public water pump. Removing the pump is said to have helped end an epidemic that claimed 600 lives. Fast forward to 2010, and the moral might be that high-tech medicine isn't always the answer and certainly not the cheapest solution to some diseases in St. Louis.

"The public fails to realize that some illnesses have an environmental influence and are preventable," says Dr. William Kincaid, former head of the St. Louis Health Department and now head of the local Asthma Coalition. "We develop systems to treat them after they happen, but we don't look upstream to see why we are having these problems. And we lose an opportunity to make some of them go away. Lead is a classic example. So is asthma."

Location influences wellness

Hope and despair run on parallel tracks in some of the worst neighborhoods on the north side. Hope surfaces unexpectedly as a motorist takes in street after street of gloomy sights, then turns a corner and finds a suburban-like setting of a block or two of stately, market-rate brick homes, trimmed lawns, fenced-in backyards and newly poured concrete sidewalks out front. These neighborhoods still include many working-class and middle-class families, some of who can't afford to leave. Others stay out of a sense of pride in a part of town that is rich in black history.

But the north side's decay is never far away. Some neighborhoods have been reduced to a treeless landscape with crumbling houses, weedy sidewalks, cracked storefront windows and closed factories. The higher than average concentration of health problems in this part of town mirrors the conditions of many of its residents. You find many here with stooping bodies, burned out by cancer and respiratory conditions, heart disease and other illnesses that are the results of inhaling too much nicotine and bad air and consuming food high in fat and low in fiber.

The stress of living in what amounts to a racially isolated, crime-ridden wasteland also takes its toll. Many residents have no choice except to settle for substandard housing, unreliable public transportation, limited access to grocery stores and the trauma of hearing gunshots and witnessing occasional fights and other forms of violence. It is a community where Larry Chavis' mom might be more likely to happen upon a crack house than a store that sells WIC-approved fresh fruits and vegetables essential to the health of her lead-poisoned son.

Just as location affects the value of property, it influences wellness. In other words, where people live and how they live matter. Last February, that point was brought into sharp focus with a study from the University of Wisconsin's Population Institute. The institute ranked the quality of life of communities within states, the first such study of its kind.

Stable St. Charles County ranked at the top. St. Louis, despite its world-class health facilities and providers, ranked at or near the bottom for most indicators, ranging from smoking to STDs. The survey showed that where people live, rather than access to clinical care, can make a big difference in health outcomes, according to Julie Willems Van Dijk, an associate scientist at the University of Wisconsin's Population Institute.

"St. Louis is a perfect example of what we're trying to show," she says. "You have very good access to care and pretty good quality of care for those who get the care. But that alone is not enough to produce good health. It's not just having a doctor. We're saying it's all of those factors working together to determine health outcomes."

The value proposition

Though the problems afflict primarily African Americans in the city's impoverished neighborhoods, Van Dijk says more affluent residents can ignore the issues only at their peril. Health disparities mean everyone is paying higher taxes to treat disease that's preventable, she says.

Matt Krueter, director of the Health Communication Research Laboratory at Washington University's Institute of Public Health, agrees.

"When you have a population of poverty experiencing all the consequences, it makes us weaker as a society and a community," he said "They are going to be less competitive in the job market. There are not just lost human consequences but financial consequences for everybody. It boils down to a value proposition and a question of what do we want our society and community to look like."

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Part Two: St. Louis struggles with its promise to care for the poor

In 1875, amid steamboats churning the muddy waterway, a tugboat came up the river from New Orleans and docked in St. Louis with an unexpected problem on board. In addition to a load of sugar from Havana, the boat carried a sick passenger. He was taken to City Hospital where the worst fears of doctors there were confirmed: yellow fever.

At the time, nobody knew the cause of this dreaded disease, but a little detective work by one physician at the hospital, Dr. D.V. Dean, turned up the answer. Noticing a mosquito bite on the patient's body, the doctor speculated that the insect was the carrier.

It would take medical science several years to confirm Dean's theory. But the incident speaks to a commitment found in the city's charter to fight disease and provide medical support for the "care of children and sick, aged or insane poor persons and paupers."

While the city's heart was in the right place, this noble promise failed to apply to black residents then and to the present day. To begin at the turn of the 20th century, blacks might have benefited from the state-of-the-art care at the rebuilt City Hospital, which opened in 1904 at 1515 Lafayette St., just south of what is now our downtown. That same year, St. Louis hosted the World's Fair, introducing millions of visitors to hamburgers, hot dog buns and ice cream cones.

Nobody is certain how many of the city's 35,000 black residents were allowed to visit the fair, but it's a sure bet that few of them set foot inside the new City Hospital. True, they might have been lucky enough to get care there for a contagious disease, such as yellow fever. Or get help for a wound from the same kind of .32-caliber revolver that Frankie Baker used during that boarding house shooting made famous in the "Frankie and Johnnie" ballad.

For the most part, however, City Hospital was built to serve whites, and it treated the health needs for African-Americans as an afterthought. This limited access to care is one of the factors that help explain how St. Louis got in the situation it now faces, a city with stark health differences between blacks and white. Some of the causes didn't start in our time. Rather, they are deeply rooted in public policy and political disputes, social conditions and economic circumstances, personal health habits, and, yes, in race.

Separate and unequal

Because blacks were shut out of care at City Hospital, many sought medical services at two small private hospitals where black doctors were granted staff privileges. They were St. Mary's Infirmary, 1536 Papin St., about seven blocks north of City Hospital and People's Hospital, 2221 Locust St., just west of downtown near Jefferson Avenue.

Rather than opening City Hospital to all, the city set up a dual medical system. Blacks were sent to City Hospital No. 2, which opened in 1919 at Lawton Place and Garrison Avenue, west of downtown in the Mill Creek Valley. This was at the site of the old Barnes Medical College, a hand-me-down, second-rate facility that African- American doctors nicknamed the firetrap. In the meantime, these doctors were denied staff privileges at City Hospital. Black patients lucky enough to get treatment in it were sent to the rear sections of the second and third floors.

Dr. Frank O. Richards, a retired black surgeon, shakes his head in wonder as he recalls that the black public hospital tried to cope with overcrowded conditions by tying together two beds at night to accommodate three patients.

But the most shocking of incidents was yet to come, says Richards. It involved Dr. Bernice A. Yancey, a black physician. He was electrocuted in the summer of 1930 when using a defective X-ray machine at City Hospital No. 2. The incident added fuel to a black political movement that culminated in pressuring the city to add money to a bond issue to build Homer G. Phillips Hospital, a first-rate facility for blacks. It was opened in 1937 at 2601 Whittier St., about two miles north and west from City Hospital No. 2 in a neighborhood known as the Ville. (Homer G. Phillips was an attorney who led the fight to include funding for the hospital in the bond issue. He was murdered in 1931 -- a crime that remains unsolved.)

Political squabbles also have affected health policy. Dr. Daniel R. Berg, a St. Louisan who has followed the history of health care for the poor in the city, says it was customary for the city to make higher per patient allocations to City Hospital than to Phillips. In 1944, Phillips got $4.84 a patient, while City Hospital was given $6.81 a patient -- or 30 percent more. By 1964, Phillips was operating with 75 percent of the per patient funding that went to City Hospital. The funding of the two hospitals was never equal until 1970, nine years before the city closed Phillips, Berg reports.

Another more dated example of political wrangling with implications for present-day health disparities involves the city's decision, regarded now with regret, to separate from St. Louis County in 1876.

"In other cities, boundaries were expanded to capture the population and the tax base, but we could not do that," said Richard Patton, director of Vision for Children at Risk, an advocacy group for children.

When the middle class began leaving St. Louis for the suburbs, the city was left with less money to cover essential services, including health care.

"People left the urban core in other cities, too," Patton said. "But in St. Louis you have to move a shorter distance before you're off the population rolls and the tax rolls than in any place else."

The upshot is that St. Louis lost population and became poorer at a much faster rate than many other cities where middle-class flight also occurred. The city's population peaked at 856,000 in 1950 and began a downward spiral. The number now stands at about 354,000, which means the city is no larger than it was 1880. On a positive note, it appears the decline has bottomed out.

Impoverished and isolated

The movement also left more people in socially isolated, impoverished and segregated neighborhoods, many of them with fewer ingredients needed to promote healthy lifestyles. Examples include convenient access to doctors, clinics and safe parks and other places for exercise.

Robert Fruend, chief executive officer of the Saint Louis Regional Health Commission, says environment and lifestyle factors are two other issues that explain health status in St. Louis. Environmental factors, he says, have led to high rates of asthma in St. Louis. He adds that Missouri's high smoking rates explain why certain chronic diseases - such as lung diseases, cardiovascular diseases and some types of cancer -- are more common in some populations in Missouri. Also common are the preventable illnesses highlighted in this series: diabetes and obesity, lead poisoning, infant mortality and sexually transmitted diseases, or STDs.

"We smoke more in Missouri and in St. Louis and low-income folks smoke at a disproportionately higher rate than other folks," he says. (He adds that targeted advertising for cigarettes and alcohol is another factor that drives disparities.)

Maggie Callon, the research coordinator who produces the statistical data for Vision for Children's annual report, observes that lifestyles are also a big factor.

"There are families, maybe generations of families, who have never shopped in a produce section of a store," she says. While she thinks people do acquire knowledge through public service announcements, she is concerned that the message is lost because "most of their friends and people they know aren't doing these things." She attributes this to "the culture of poverty in very concentrated areas."

Ideals 'lost in time'

Meanwhile, Patton says, the situation involving health disparities and child poverty in particular could be turned around.

"We need to start with political will," he says. "We always hear what terrible shape the Missouri budget is in. Well, we still invest billions of dollars in Missouri in certain types of things that could be invested in other ways to address certain problems. If you want to pull up the economy, you do what we need to do for kids and families. Study after study shows that it's the investment in human capital that pays returns."

More health resources clearly are needed in many north side neighborhoods where health disparities are the greatest. The three city zip codes identified by the Beacon as having the most dramatic health-care disparities are 63113, 63106 and 63107. They are home to about 43,000 city residents, representing about 12 percent of the city's population. Yet fewer than 1 percent of the city's primary care physicians practice in the zip codes.

St. Louis has a rich history of trying to solve medical mysteries, whether it's the City Hospital doctor working alone to figure out the cause of yellow fever 130 years ago, or a high tech research team seeking to uncover the mysteries of cancer in our time. But Dr. Berg suggests there is a lot of unfinished business.

He writes that "there is an entire underclass within the city that suffers from health outcomes more comparable to the Third World countries than to our neighbors in west St. Louis County. The ideals of the city founders have been lost in a sea of time."

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Part Three: Mothers find state WIC rules create obstacles to getting nutritious foods

The low-rise building at Cass Avenue and 14th Street is now a used-car lot, but many neighborhood residents still remember it as Salama, a corner grocery. It stocked some nutritious foods and infant formula as part of the federal government's WIC (Women, Infants and Children) program to help disadvantaged residents raise healthy young children.

About four years ago, federal officials accused the store and a half dozen other corner markets of mismanaging WIC and removed them from the list of approved vendors.

This well-meaning decision had an unintended consequence. It meant that hundreds of needy mothers and children, many of whom did not own cars, no longer had access to convenient places within their zip codes to buy the protein-rich food supplements under WIC. Salama was across the street from the O'Fallon Place Apartments, which serves low- to middle-income tenants who used the grocery after a nearby full-service supermarket closed.

The federal actions against the corner groceries had far-reaching consequences. Replacing them with other corner store merchants has been impossible because Missouri's rules have changed. The state now requires that WIC products be available exclusively in full-service supermarkets, which are rare in most poor neighborhoods. Not all states have this requirement.

Items that the state requires all stores to stock include cold and hot cereals, fruit juices, milk, soy milk, cheese, eggs, dry beans and peas, peanut butter, meats, fruits and vegetables for infants, along with fresh and frozen fruits and vegetables.

Carolyn Dickerson, a mother in her 20s, had been among Salama's loyal customers. Thanks to help from the highly regarded Maternal, Child and Family Health Coalition, Dickerson learned early to turn life's lemons into lemonade. The shutdown of Salama probably became a disincentive for some who didn't want to bother with the inconvenience of taking buses across town to find a supermarket that sold nutritious foods. But not Dickerson, then pregnant with her first and only child, now 4.

"I did what I had to do," she says. "I was determined not to let my condition prevent me from reaching my goals."

Still, she was not exactly happy about losing access to WIC products at Salama.

"Yeah, I was kind of mad," she said. "When it was cold, I could handle that. But the snow made it harder for me. Unless I had a ride, it meant taking the baby back and forth on the bus to get food."

Fewer chances to make good choices

The loss of access to nutritious foods on the north side is an example of public policy failing to keep pace with new thinking about the health-related causes and consequences of living in poor neighborhoods. Policy makers are learning that illnesses and poor health aren't simply the result of people making bad choices. They are finding that people living in many urban neighborhoods have fewer chances to make good choices.

Cheryl Kelly, an assistant professor at St. Louis University's School of Public Health, did not have WIC in mind when she commented on giving people the options to make healthy choices. But her thoughts apply just as well to WIC products.

Kelly's research has documented locations where it's hard to find nutritious foods. Her work has also spotlighted areas with poorly maintained sidewalks and parks in parts of St. Louis and St. Louis County. She suggests that people's attitudes about healthy eating and regular exercise are influenced by these factors.

"At the end of the day, people will make the choices they want to make," she says. "They may choose to smoke or go to McDonald's or sit on the couch and watch TV. But if we make it easier for people to get fruits and vegetables to eat, make parks safer for exercise, people may be more likely to do those things."

She says public policy should focus on building "the most ideal environment to support people making healthy choices."

If a child lacked convenient access to food assistance given away by the federal government, the thinking used to be that the onus fell on the family to figure out a way to get to alternative food sites. That meant poor people were expected to show the kind of grit that made Dickerson rise on cold, snowy mornings or hot summer days to catch a bus to a grocery store even if it were halfway across town.

Of course, people who live in better neighborhoods don't have to summon much determination at all. They can take it for granted that a well-stocked grocery is nearby, and they don't have to rely on public transportation to get there.

Public health practitioners in particular have begun calling attention to a possible connection between health outcomes and convenient access to healthy foods, including WIC products, that can lead to healthier pregnancies and births. The access not only contributes to a healthier newborn, but it can help avoid later hospital and medical costs associated with problem pregnancies and sick children. It not only helps the families involved, but those in the suburbs who pay taxes to support a broken health-care system.

Five thousand families with little access to supermarkets

The absence of decent supermarkets to buy WIC-approved foods is acute on the north side among mothers with fewer than 12 years of schooling. Many don't bother to get any prenatal care during the crucial first trimester of pregnancy. Many of them live in neighborhoods and zip codes where full-service grocers with WIC products are less plentiful or nonexistent.

According to state data, the northern end of the city is perhaps the most underserved in terms of access to full-service supermarkets. Nearly 5,000 families served by WIC live in that part of town, but they can count only seven stores where needy mothers can buy WIC supplies.

On the other hand, there is no shortage of stores offering less healthy foods. The dilemma is summed up by two billboards that stood side-by-side during part of the summer at North Florissant and Chambers Street. One featured two wholesome-looking infants and messages suggesting that every low-income mom could give birth to babies like these if she took part in the WIC program. The other billboard promoted a sugary soft drink with the slogan, "There's nothing like a Pepper."

Of course, you can buy a Dr. Pepper practically anywhere. But that's not the case for WIC-approved foods. Missouri seems to have taken an all-or-nothing approach to WIC foods. A grocer must carry them all, or it cannot participate in the program.

Randy J. Walton, the state's WIC vendor coordinator, says he wishes WIC outlets were more plentiful. The Missouri WIC program, he says, constantly looks for additional vendors.

Walton also notes that state policies are governed for the most part by federal rules. He was asked about the possibility of dispensing WIC products at community health centers, churches, food pantries and other unconventional locations to make the products more accessible to needy women.

"Local health centers are not set up to stock and sell WIC foods," he says. "Only a full service grocery can provide all the approved WIC food items."

In some instances, he says the stores removed from the WIC-approved list were decertified for shortcomings ranging from failing to carry all the required WIC products to fraud. He didn't comment specifically on the Salama case except to say, "I can tell you that (the charges) were serious."

He added that the merchant was disqualified for three years and had the option to reapply, provided the market met all changes in the new qualifications. Salama would not have met them because it is not a full-service supermarket.

"WIC participants must be able to get all of the WIC food items listed on their WIC checks at any WIC approved store," Walton says.

Asked who made this policy that, in effect, limits WIC to full-service supermarkets, Walton said that policy resulted from "careful consideration of the program costs and the needs of the participants." The goal, he said, was to make all these WIC-approved foods available at a single location so participants wouldn't have to travel to several stores to get them.

When merchants are taken off the WIC list, Walton says state officials review all WIC-approved stores in the immediate area and the distances moms might have to travel to get food. The state, he says, wants to make sure other stores can meet the needs of WIC participants. He provided no specifics about the allegations against stores that have been decertified, but he said it would be unfair to allow any store that committed violations to remain in the program.

Neighborhood grocery thrives without WIC

Khaled Salemeh, owner of the old Salama food market, said he had been a WIC vendor for 15 years before the state's action.

"They said we didn't keep enough stuff," he says. "Not true, not true. I'm providing every service the big guys (major supermarkets) are providing, from clothing, to hair products, beverages and groceries."

He alleges that the crackdown was aimed at putting small merchants out of business, a notion that Walton strongly denies.

Oddly, the loss of the opportunity to sell WIC products hasn't hurt Salemeh's business. He vacated the old store at 14th and Cass and moved to a new facility at 1513 North 13th Street. There he has opened a new collection of stores, called Salama Crown. It's a block long business, including food, package liquor, a beauty supply store and a sporting goods store.

On most days, he occupies a glass office, working a calculator and monitoring activity inside the food mart. On a recent Sunday, the store was doing plenty of business from people buying gas at the Mobil pumps outside and treating themselves to snack food, a small selection of fruits and vegetables, and fried chicken and other items served in its deli section.

Salameh employs several clerks, and the complex is nicely landscaped with a low level black fence surrounding the oblong building. On one end, next to the car wash, stand rose bushes still blooming on a breezy Sunday afternoon.

"I have 20 years of experience, and I'd like get back into the WIC program," he says. "Now look what has happened, the big guys have left and we're the only store willing to stay and serve people."

Salameh has a business that seems to have many of the items most of his customers want. What's missing is a large supply of fresh fruits, vegetables, meats and beans. And a WIC license that's now provided only to full-service supermarkets.

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Part Four: Co-op is oasis in urban food desert

Using his fingers to rake away ankle-high weeds on a plot next to his house, George Banks finally looks up with a smile after spotting something that a visitor doesn't immediately see.

"There," he says as he slowly straightens his stout body. "Watermelon vines. Got some collards coming up, too."

Whenever his arthritis, heart disease and diabetes cooperated last spring and summer, Banks, 63, spent time tending his garden in Old North St. Louis.

The work is not a hobby but a necessity. His health problems require him to eat plenty of fresh vegetables. Because no full-service supermarket exists in his neighborhood, Banks relies on his garden for some food.

"We got a lot of sick people around here," he says. "Some of them don't have cars to get to grocery stores. We need a Schnucks down here."

Instead of a Schnucks, residents got perhaps the next best thing. On a sunny Saturday morning in July, the Old North St. Louis Restoration Group opened a 2,000 square-foot food co-op at 2718 13th St., a block east of Crown Candy Kitchen, an Old North landmark. The co-op is one of the group's responses to the community's food desert. The term refers to places where residents lack access to full-service supermarkets and must travel miles away from their homes for fresh fruits, vegetables and other nutritious goods.

The group's other approaches to helping people find food in this desert include a farmers' market, community gardens and special arrangements for farmers to deliver foods to families from spring to fall.

These options have not kept residents like James Smith from wishing that a huge supermarket would find its way into the community. He's a fine artist in his 60s and a resident of Jackson Park Senior Apartments, just two blocks east of the co-op.

A long trip to the supermarket

Late Sunday morning, when the neighborhood was quiet, Smith alighted from a bus at his apartment building, carrying two pink grocery bags. He was returning from a shopping trip to Schnucks, at 5055 Arsenal St. in south St. Louis.

"It takes about an hour each way," he says. "It's another reason we need a grocery store in this neighborhood. There is a store closer to me, but the quality is so bad, I wouldn't even buy food for a dog from there."

He was asked about the co-op, which opens on late afternoons, Monday through Friday, and from 9 a.m. to 3 p.m. on Saturdays.

"It's not open on Sunday, but the hours aren't the problem," Smith says. "It's convenient, and I'm glad it's there. But they don't seem to offer much variety."

Cheryl Kelly, an assistant professor at St. Louis University's School of Public Health, isn't surprised when she hears that residents in a food desert are slow to embrace a farmer's market or co-op.

"People have been living their lives in a certain way for a long time," Kelly says. "So just putting a farmer's market in is not going to make that go away."

She says education and outreach can help encourage people to take full advantage of good alternatives to full-service grocery stores.

Benefits for farmers as well as city residents

Whether Banks and Smith realize it, Old North made history on the day the co-op opened. Its significance was indicated by the number of public officials who showed up to cut the ribbon. Gov. Jay Nixon wasn't there, but he dispatched the state's agriculture director, Jon Hagler, to stress that the opening was a very big deal. The arrangement offers a way of bringing urban and rural interests together, boosting business for farmers, and giving urban residents "access to affordable, healthy and local food where possible," Hagler said.

Although the region surrounding Old North is predominantly black, whites seemed to make up most of those at the co-op on opening day. Sean Thomas, executive director of Old North, says there are enough people in the area to support the co-op.

"Based on census data, 13,000 live in Old North and all the neighborhoods that touch it," Thomas says. "We don't need huge volume. What we need is constant flow or regular customers to sustain it."

He says 41 percent of residents in the area lack access to cars. He adds that the site is conveniently located for people who use one of the two bus lines that makes stops at or near the facility.

Thomas says it might be unrealistic to expect a grocery chain to put a store in Old North.

"The supermarket industry has evolved into larger and larger stores serving broader areas with lots of space for parking, lots of traffic and large population bases," he says. "So this area was not an area on their radar. The area is labeled low income. Grocery stores would like to be in higher-income areas."

Counting on health benefits

Thomas says the success of the co-op will be judged less by the volume of business than by its impact on health.

"Obesity and cardiovascular disease could be traced to health, diet and limited options for available and accessible food options," he says.

 

He adds that the area is typical in that many vendors offer food high in fat and calories without a lot of nutrition.

"If your diet gets filled up with that, it's not surprising that people end up with high incidences of heart disease and diabetes," he says.

Banks, the gardener, knows as much. Last spring, he mentioned the "blockage in my heart from eating lots of greasy food, lots of fried food. It took a long time for it to catch up with me."

Old North straddles two problem zip codes -- 63106 and 63107 -- where, in Banks' words, there are "a lot of sick people." For example, mortality from diabetes in the 63106 zipcode was 71.9 per 100,000, according to a St. Louis health disparity study released last year. This rate compares to 37.4 per 100,000 for the city in general and 47.3 per 100,000 for the black population nationally. Similarly, cancer and heart-related deaths far outstrip those in the city as a whole and in the national black population as well.

Banks said that his own experiences with heart disease and diabetes have taught him to "eat a whole lot of vegetables, less salt and lots of baked food. But lots of people around here eat bad food, lots of people. They aren't sick yet, but they will be."

During the third week of October, this visitor returned to the old north St. Louis neigborhood, curious about how Banks' watermelon turned out. Banks was not at the A-frame brick home, where he lives alone. A lone rose bloomed in a bush next to a red brick wall, discolored by heavy tuckpointing.

In the garden, a few collards still grew. But there were no signs of watermelon vines. Perhaps they didn't make it past the spring, like some other things that bloom briefly and die early in a food desert.

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Part Five: City parks and sidewalks play a role in health disparities

With plenty of trails for walking and jogging, biking and rollerblading, Forest Park stands out as one of the nation's largest urban green spaces for recreation. It's also safe and well-maintained, factors that explain why people find it an inviting, carefree place for putting their hearts and limbs through robust exercise.

But a research team from St. Louis and Washington universities found a different story when it surveyed conditions in many other area parks, particularly those in the city. The team looked at equipment, such as tennis courts, goal posts, slides and bike trails; it also reviewed physical disorder, such as garbage and graffiti. More than half of city parks were in the highest third for physical disorder, and only about 21 percent were in the highest third for good equipment, according to one of the researchers.

One researcher, Cheryl Kelly of the School of Public Health at Saint Louis University, also was the lead researcher for a separate St. Louis study, which looked at walkability issues, such as uneven sidewalks and other problems that may discourage people from walking for exercise in the city.

Although walking is viewed as an inexpensive way to exercise, it turned out to be much harder to do in black neighborhoods because their built environments did not support walking for recreation or transportation. Her study found that African Americans wanting to walk for exercise were a lot more likely to encounter uneven sidewalks, obstructions and physical disorder.

Kelly is not surprised by the state of some urban parks or sidewalks, but she is still alarmed because the numbers tell her a lot about other conditions in the neighborhoods. Like many other public-health experts, Kelly says broken-down park equipment and poorly maintained sidewalks give residents an excuse not to use them for exercise. That in turn could mean people are getting less physical activity in general, which Kelly says is a factor associated with health disparities, such as obesity and some chronic diseases and conditions.

Many public health practitioners say society needs to pay more attention to how environmental factors -- such as no safe places for exercise -- contribute to disease and focus, too, on making parks and sidewalks more attractive places for residents to exercise.

Everybody Pays

This issue may seem remote to those St. Louisans who get their exercise in safe and secure places, such as Forest Park, but it's in everybody's interest to promote physical activity to help prevent disorders, such as diabetes, says Julie Willems Van Dijk, a scientist at the University of Wisconsin's Population Health Institute. She says society has moral reasons to be concerned, along with the fact that unhealthy people and neighborhoods do not make for strong communities.

Beyond those reasons, she adds, are the higher costs, direct or indirect, to subsidize health care associated with such illnesses as diabetes.

"This issue is important to middle-class people," Van Dijk says. "Poor people are more likely to be on Medicaid and supported by tax dollars."

Just last week, the Centers for Disease Control and Prevention issued a projection on the rapid spread of diabetes and the cost. It said one in 10 adults now has diabetes, and that in four decades the number might increase to as many as one in three. The CDC study says the current cost of addressing diabetes is $174 billion a year, including $116 billion in direct medical expenses. Getting a handle on obesity is crucial because it can reduce diabetes. The disease, beyond the costs, causes a great deal of suffering with patients having to deal with amputated limbs, kidney disease, failing eyesight, heart attacks and strokes.

Debra Haire-Joshu of the Brown School of Social Work at Washington University says researchers began taking a closer look at the connection between disease and environment as Americans began developing diabetes and complications at younger ages.

"We started seeing disparities in certain racial and economic groups," she said. "It became clear that all this was preventable."

She realized as much as she began to look beyond the clinical setting to the natural environment, trying to understand where people lived, how that influenced what they ate and their other activities. Even if people were informed enough to know what to do, "they were in an environment that fought against them doing that," she says.

She adds that, "If someone lived in an area where there's high crime, broken sidewalks or no sidewalks at all, if the parks are in poor shape, then it's very difficult to be active because there are safety issues and concerns."

Last Sunday afternoon seemed like an ideal time for walking in O'Fallon Park. Except for one thing -- some people might have felt uneasy about using the walking path. Occupying it was a stray dog, a mixed pit bull, who probably was less menacing than she looked. Another section of the trail was controlled by a woman and child using the path as a race track for their go-cart. Likely both the go-cart riders and the animal would have politely stepped aside for walkers, but the presence of these two elements probably gave people disincentives for using the trail for walking.

What Works

In spite of the conditions of parks on the north side, there are places where residents can find safe places to exercise. One is the Monsanto YMCA, where Dr. Consuelo Wilkins, an associate professor at Washington University Medical School, hosts a popular physical education program for what is said to be the largest group of African-American elderly in the nation. Wilkins smiles when she says the program is for the elderly who assumed that getting old automatically meant they had to endure a lot of pain.

Her goal, she says, is to show these older adults that aging and illness don't have to go hand in hand. She's helping them learn that they can remain fit and independent and deal with health conditions that their bodies might have begun developing during a time when medical services were segregated and inequitable. The program is called CARE, which stands for Collaborative Assessments to Revitalize the Elderly.

The Y's membership fees range from $40 for individuals to $54 for a full family membership, but the agency says many members get subsidies. The agency offers one of the best, if not the best, exercise equipment and pool for residents living north of Delmar. Membership exceeds 4,000, Y officials say.

In addition to the Y, groups such as Trailnet sponsor many activities to make it possible for residents in underserved communities to get exercise in safe environments. One example is its Open Streets event earlier this month in the Old North St. Louis area. Trailnet was instrumental in getting the city to pass the first Complete Streets policy in St. Louis. The policy says the city must take into consideration all users -- the elderly, children, walkers and bickers as well as automobile users -- when it designs, builds or maintains a roadway.

Cindy Mense, director of community development at Trailnet, adds that St. Louisans can do much to revive north side parks that are shunned because they are perceived as being unsafe or in poor shape.

"People aren't going to feel safe if other people aren't out there," she says. "What's likely to bring people out is how clean it (the park) is and if you have programs and events to engage people."

An example, she says is Ivory Perry Park, which many St. Louisans might have perceived as unsafe at one time. Yet this park is one place where local artists, such as Denise Thimes and Kim Massie, host summer concerts that draw diverse groups of people.

"People start seeing things differently when you have programs and events," Mense says. The more a park is used for events, the more the perception about safety goes up. But if it's abandoned, the trail is empty and there's a stray dog running around, nobody's going to go there."

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Part Six: BODDY building: Washington University program helps St. Louis residents shed pounds, regain health

There have been times when Tracy Blue's mood was a perfect match for her last name. She was often irritable and occasionally depressed as she coped with Type 2 diabetes and the burden of carrying as much as 254 pounds on her 5'4" frame.

During the past year, however, her health has improved and her weight has dropped, thanks in part to an exercise and counseling program tailored to African Americans like herself. Called BODDY, the program operates out of the Monsanto YMCA in north St. Louis and is run by Washington University's Health and Nutrition Center.

The exercise, diet and counseling allowed Blue to discontinue some medications, including those to treat her diabetes. She now believes the various medications were affecting her mood. Blue's approach to diabetes may be the exception instead of the rule. In addition to diet and exercise, many diabetics also need insulin and other medication to control their blood sugar.

"I've lost weight. I feel better. I'm off the medicine and I'm happier," Blue says.

BODDY shows one consequence of offering overweight people a place to focus on fitness and exercise in safe environments. Researchers are discovering that a neighborhood's environment not only affects health but also influences the extent to which people engage in healthy activities. Those principles seem to play out when Blue is on her way to work some mornings and sees women like her trying to take brisk walks in O'Fallon Park.

"They walk with sticks in their hands, afraid of the dogs, I guess," Blue says.

That image evoked apprehension in Blue. It's not that such predatory behavior occurs frequently, but the perception that the park is unsafe influences whether and how often residents such as Blue are willing to use it for brisk walks, jogs and other forms of exercise.

OBESITY IS ALL TOO COMMON

Blue's weight and health problems are common among black women. Federal studies show that about 80 percent of them are overweight or obese, the highest percentage of any U.S. group. Michelle Obama's Let's Move program has tried to call attention to the fact that Americans of all ages are getting fatter and suffering preventable health problems -- such as Type 2 diabetes -- that are thought to be triggered by or complicated by being overweight.

Blue adds that outsiders might not understand some cultural reasons black women don't exercise as much as they should. For some women, she says, it boils down to deciding whether to exercise and watch their curls wilt from the sweat or avoid exercise to protect their permanents. White women might be able to simply shower, shampoo and use a blow dryer to look great, but she says it isn't as easy for black women to work with their hair.

A BRUTAL SELF-ASSESSMENT

Now that Blue sees improvements in her health and weight, she talks more freely about incidents that used to cause painful embarrassment. Take, for example, vacation pictures that usually trigger wish-I-were-there-now memories in most people. But not Blue. Certainly not the snapshots with girlfriends, all smiles and in color outfits, looking into a camera during a trip a few years ago to Jamaica. Blue hadn't thought much about the pictures until the day a relative saw one and spoke before catching her tongue. With unintended cruelty, the relative said, "Look at those fat-ass women in that picture!"

That was about two years ago. Recalling that moment this summer, Blue lets out a giggle, a deep one that lasts so long she puts a hand to her throat to constrain herself. Then she talks about photos from another trip, this one to Des Moines to take in an opera. Those photos led Blue to make a brutal assessment of her physique.

"I was in plaid shorts," she recalls, "and I was huge. I was like, 'Wow, am I fat!' "

If she hadn't conceded as much, her body would have. Whenever she stood up, her body kept reminding her how difficult it was to support her weight.

"I'd have to wait before I could start walking. My knees would hurt, my clothes weren't fitting me, and I decided it was time to start losing weight because things had gotten really, really bad."

It helped that an ad in the St. Louis American, a black weekly newspaper, caught her eye more than a year ago. In addition to offering help to African Americans coping with weight problems, diabetes and bouts of depression, the ad offered a year's membership in the Y. The membership is $40 a month for individuals, a price that wasn't too steep for Blue, a woman with two college degrees and work experience in fields ranging from business to social services.

HARD WORK PAYS DIVIDENDS

BODDY turned out to be a good fit for Blue. Its catchy title stands for Beating Obesity, Diabetes and Depression at the YMCA. The principal investigator, Rick Stein, wanted to find out whether attacking weight, diabetes and depression in a controlled setting such as the Y would have a positive impact on the lives of the participants. He says that BODDY has the potential to alleviate depression, improve a person's quality of life, decrease body weight and reduce the risk of chronic heart disease in obese African Americans with Type 2 diabetes.

Stein believes the Y-based program holds much promise. Judging from Blue's results, the program certainly raises the question of whether some obese diabetics with other physical ailments might benefit as much from counseling, dieting and a free membership in a gym as they might from taking medicine.

"I knew it was going to be hard," Blue says. "They don't hold your hand and force you, but they give you all the tools to lose weight -- meal plans and what to eat. It's really an intensive program. When I started losing weight, I didn't have problems with my knees anymore."

Blue was quite familiar with diabetes long before she was diagnosed about a decade ago. Both her parents are diabetics, and her maternal grandmother had both legs amputated because of the illness.

"She died of breast cancer," Blue says of her grandmother. "But I didn't want to be like her with both legs amputated. I told myself, 'No way.' "

That's another incentive, Blue says, to lose pounds and take better care of herself.

The challenge, says Stein, is to convince patients not to gain back the pounds, which can harm their health. Blue says she doesn't expect that to happen. In fact, after she completed BODDY's program last month, she bought her own membership to keep up her exercise routine.

That's another reason Tracy is no longer blue.

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Part Seven: St. Louis gets the lead out

The lobby of the Winston Churchill Apartments at Cabanne and Belt avenues undoubtedly reminds some visitors of the elegance of a bygone era. It's a massive room with green and beige walls, a fireplace, eight comfortable sofas and lots of chairs, all on a shiny, marbled floor. The soft colors and quiet setting recall the time when the building and surrounding neighborhood were home to upper-middle class St. Louisans.

These days, tenants of modest means live in the eight-story building, now fully renovated after falling on hard times. One measure of protection offered the new tenants and unavailable to rich occupants decades earlier is lead-free paint. In fact, the rehabbed Winston Churchill apartments -- named, by the way, for the St. Louis poet and not the British statesman -- marked one of the turning points in the city's war against lead poisoning. The developer's decision to make the building lead free in 2008 caused a light bulb to glow in the mind of Randy Mourning, a building division worker. He suggested that the city track developers spending millions of dollars to renovate buildings and encourage them to do the work in a lead-safe manner.

The idea, which earned Mourning a service award from Mayor Francis Slay, is one example of the public-private collaboration that has helped St. Louis make major strides against lead poisoning, says Jeanine Arrighi. She's the city's manager for children's environmental health. As is the case with many other illnesses, where children live influences the extent to which they are likely to be afflicted by lead poisoning.

When it comes to lead poisoning, bad housing is the biggest but not the only culprit, Arrighi says. She points to information from federal and state health officials who say lifestyles and bad eating habits also play a role. In addition to urging families to keep children out of the way of lead dust and lead-tainted paint chips, the officials says nutritious foods are a weapon to prevent the bodies of children from absorbing harmful levels of lead.

GETTING A HANDLE ON THE PROBLEM

To nobody's surprise, the problem is more severe in poorer neighborhoods on the north side. What is surprising, however, is that the city is finally getting a handle on the problem and is learning how to reduce and prevent it.

Children are considered to be lead poisoned when their bodies contain at least 10 micrograms of lead a deciliter of blood. Some scientists argue that even fewer micrograms can put children in the danger zone. Lead poisoning rates have been part of city Health Department reports for at least 39 years. During 27 of those years, the childhood lead poisoning rate has been 10 percent or higher -- and as much as 48.5 percent in 1992; 34 percent in 1972; 32.3 percent in 1973, and 31.1 percent in 2000.

"Right now," Arrighi beams, "the rate of lead poisoning in the city is a little under 3 percent. We've made tremendous gains. The drop in the lead poisoning rate in St. Louis was 71 percent in a period from 2000-2005. The rates in a number of other cities have dropped 61 percent. So we're doing better."

Aside from worrying about lead levels in general, Arrighi says the city keeps watch on the number of children with more than 20 micrograms of lead a deciliter of blood. That's the level at which the Centers for Disease Control and Prevention says intervention is absolutely required. In 2003, Arrighi says there were 217 such children. Last year, there were 68.

"I'm so proud of what everybody has done," she says, adding that the city's own intervention threshold is much lower -- 10 micrograms of lead a deciliter of blood.

Slay is elated, too, saying the results show that the city is doing more to protect vulnerable children.

MORE WORK TO DO

Everybody concedes, however, that even more needs to be done since the drop only refers to children who have been tested. Still, the decrease is substantial for a city that, until now, has been unable to get a handle on its lead problem.

So what made the difference?

Arrighi says the turnabout began after Slay set up Lead Safe St. Louis in 2003. Slay said the high lead levels were unacceptable, and he demanded that agencies work together to address the lead problem. The big challenge was to address lead contamination associated with windows and doors, Arrighi says.

"People in low-income households without air conditioning open their windows in the spring. The friction (from opening the windows) releases dust into the window sill and kids have easy access to that. That's a huge exposure risk. It's the lead dust that accumulates in the trough of the window. When the window is open, that accumulated dust blows into the room."

She adds that the location is "the perfect height for little ones at play to run their cars and trucks on the window stool along the trough." This exposes them to the lead dust. Meanwhile, the doors in these homes are a problem because opening and closing them knock paint chips and dust onto the floor.

Aside from more collaboration among city agencies, Arrigh says landlords have bought into the program. They became partners in the fight against lead around 2007 after the city set up a window replacement program, an idea first suggested by a local advocacy group called Health and Environmental Justice. The idea is based on a similar program in Milwaukee that replaced faulty windows. Under that program, the city foots the bill for up to 10 replacement windows a unit, with each window costing up to $200. In exchange for this free upgrade, landlords agree to allow inspectors to check the property. The landlords also agree to remediate any other lead hazards identified during the inspection. City officials say the program is out of money for now, but they hope to revive it.

Arrighi believes the window replacement program led once reluctant landlords to embrace the city's programs.

"We saw hundreds of landlords participating," she says because the new energy-efficient windows added value to their property.

CREATIVE FUNDING

Plenty other challenges have appeared along the way, one of the biggest being money. The city addressed that in part by setting up a lead remediation fund, financed by a $2 charge for every $1,000 of the estimated value of a building permit. Arrighi says the fund has generated about $1 million a year, with the proceeds used as matching funds to help the city capture close to $20 million in federal lead grants in the past decade.

Arrighi stresses that it's really in everybody's best interest to address the lead hazard. She says the city's efforts so far have prevented 4,000 children from being poisoned by lead. She points to a study that found the estimated economic benefits of lead-poisoning prevention:

"If you have two 2-year-old children and one is lead poisoned and the other isn't, the one with lead poisoning would be expected to earn $723,000 less (over a lifetime) than the one who isn't," says Arrighi.

Multiply those earnings times 4,000 kids, Arrighi says, and the public will see a benefit of $2.9 billion, compared to the estimated $20 million the city invested in its anti-lead program.

She adds that the public shouldn't forget that prevention also helps avoid the cost of treating the physical and mental disabilities that can result. She adds that other studies are "correlating lead poisoning to crime rates in communities." While conceding that the theory is controversial, Arrighi adds that some researchers believe lead poisoning "impairs the development of children to make good discretionary decisions. Behavior is not easy for them to control."

Besides the city's own funding efforts, Sen. Christopher S. Bond, R-Mo., persuaded federal housing officials to give millions of dollars more to fight lead in St. Louis. He requested that Grace Hill health system run the program. It was limited to between six and nine zip codes having the highest prevalence of lead. The program made sure that homes of poor mothers in those zip codes were lead safe before their babies were born. Grace Hill officials said funding for that program has run out. The city is continuing it, Arrighi says, through relationships with the OB-GYN clinics at Barnes-Jewish Hospital and St. Mary's Health Center. Staffs at those clinics refer pregnant women to the city's program, which makes sure the homes are lead safe before the mothers give birth.

In addition, Arrighi says, the city lends families high-efficiency vacuum cleaners. Fifteen of them were bought through grants from the Environmental Protection Agency and the Department of Housing and Urban Development.

A NATURAL FOR THE JOB

Arrighi probably had no idea the city would make even this amount of progress when she landed the job as coordinator of the city's anti-lead initiative. She turned out to be a natural for the job for several reasons. Although she has a degree in architecture, Arrighi was an environmental consultant with an environmental training business and had done her first lead inspection in 1991. Her own business and work experience, she says, had helped her "understand how the renovation, repair and repainting process can disturb lead if the contractors aren't using appropriate work practices."

The city's success against lead raises a question. Why has it not been as effective in tackling some other health problems, including sexually transmitted diseases?

"I suppose our success in the last six or seven years has been because the mayor really prioritized this and said it's just not acceptable and we have to turn this around," Arrighi says.

The mayor also stressed that the city couldn't solve the problem alone, she says. That led to partnerships with community groups, such as the Child Day Care Association, Catholic Charities and the Jewish Community Relations Council. The latter, she said established a speakers bureau and reached out to the medical community to encourage doctors to increase testing rates for lead. The day care association worked with home-based day-care centers to encourage them to undertake lead remediation of their properties.

Meanwhile, she argues, some public-private partnerships, like the city's anti-lead initiative, can freeing up public-health workers. They can then "look at other health issues and how we can address them, asking what are their causes and the barriers in our way to eliminating those causes."

One such issue, says Dr. William Kincaid, is asthma. He's head of the St. Louis Asthma Coalition. In fact, he and Arrighi say the city is gearing up to use its experience in addressing lead poisoning to wage a similar campaign against childhood asthma.

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Part Eight: Rescuing Larry: Public health workers help a worried mom save her child from lead poisoning

Nothing speaks louder to a mother than a silent child.

When Larry Chavis was about 2, he'd sit in the middle of the floor in a room full of teddy bears, toy cars and trucks, but he didn't seem interested in playing with them. His perplexed mother, Achaia Robinson, sensed something wasn't quite right with her son; she was confused by his dazed look and his tendency to keep to himself.

"He was just lying around; he wouldn't play and wouldn't eat," she says. She later learned from medical tests that her child didn't seem like himself because he was suffering from a serious case of lead poisoning.

Public health officials are alarmed when a child's blood-lead level is above 10 micrograms of lead per deciliter of blood. Larry's level of 28 micrograms was nearly three times the acceptable limit. (A microgram is a millionth of a gram; a deciliter is one-tenth of a liter.) The small numbers show how little lead needs to be absorbed into the body before it harms a child.

After coming to grips with the reason for her son's behavior, Robinson prepared for the time when she assumed he'd be taking plenty of shots and pills -- and perhaps suffer through painful chelation treatment for removing the lead. But she discovered that the remedy for his lead level was so simple that doing it after Larry's birth might have lessened or prevented the unacceptably high level of lead from building up in his body.

"They told me to feed him plenty of fresh fruits and vegetables," Robinson recalls, sounding a little puzzled by this relatively easy solution to such a serious health problem. It's a remedy that surprises many people who have never been told the value of a healthy diet in fighting and preventing lead poisoning.

That's because the public tends to think about the problem only in the context of a child's exposure to lead dust and peeling paint in older homes, and not alternatives to these problems. Many parents are unaware that they can be proactive by feeding their children calcium- and iron-rich foods.

EDUCATION IS A KEY TO PREVENTION

Every city and state health agency, along with federal agencies such as the Environmental Protection Agency, include this message on their websites and in their brochures. Aside from encouraging hand washing and keeping their kids out of the way of lead hazards, parents are urged to provide youngsters with regular meals because empty stomachs absorb more lead. They also are told to avoid feeding their children fried foods and to limit their intake of oily foods, potato chips, cakes, cookies, doughnuts and other foods high in fat.

Typical advice is on the Missouri Department of Health and Senior Services' website. It reminds parents, childcare workers and others that iron-deficiency anemia has been associated with increased susceptibility to lead poisoning.

LIFE IN A FOOD DESERT

It's advice that families in suburbia and solid neighborhoods in the city find easy to follow since many have access to convenient grocery stores and tend to encourage their children to eat healthier food. But even if most poor families in St. Louis made the connection between fresh foods and lead, some of them face a hurdle. Full service supermarkets tend to be limited or nonexistent in some St. Louis zip codes or neighborhoods where poor children seem most vulnerable to lead, says Jeanine Arrighi, the Slay administration's manager for child environmental health issues. She adds that some families do not routinely make sure their children get enough fresh fruits and vegetables.

"We know our diets in this day and age are not as good as they were 30 or 40 years ago," she says. "Kids don't eat good healthy food the way you and I ate as children. There's too much fast food and there's the food desert. Kids don't get the calcium and iron they need to help their bodies protect them from the lead exposure."

At one time, a full-service grocery store was located about half a mile from Robinson's home. After that store closed, the closest high-quality food store was built about two miles away. The family home is closer to fast-food outlets and a service station that doubles for some residents as a mini-grocery store. But Robinson says that after lead became an issue, she chose to feed Larry plenty of fresh foods and give him beverages with less sugar as well.

She says it helps that he isn't the type of child who thumbs his nose at spinach and other healthy foods. Still, research shows that making full-service groceries convenient can influence whether families shop at nearby corner stores or visit the supermarket that might be several blocks or miles away.

RESCUING LARRY

In any case, convenient access to fresh fruits and vegetables seemed to have been a secondary issue in Larry's case. He was poisoned by lead dust and chipped paint in the two-story rented house where the family still lives. His high level automatically triggered the city's response of addressing lead hazards in the windows and porch at the house, moves that have helped to reduce the child's lead problem to an acceptable level.

The city's program includes replacing windows, repainting rooms and addressing other lead hazards -- and it works. Robinson is thankful for it, saying, "my son would be really sick" had the city not stepped in. Because of a steady diet of fresh foods, the repainting, the cleaning and medical attention, Larry, now 4, had a lead level down to about 5 micrograms by this summer, well within what's considered a safe limit.

MORE WORK TO BE DONE

Arrighi has thought a lot about Chavis' case, remarking that "our goal is to eradicate lead poisoning." The city is far from doing that, but it has made lots of progress since 2003 when Mayor Francis Slay declared war on lead by starting his Lead Safe St. Louis program. Before then, environmental groups had complained that it would have taken the city a century to address the problem had it stayed the course of trying to find money to completely remove all the lead in older homes rather than replace windows and doors in housing and neighborhoods where the lead problem was worse. Because the city has now chosen to focus on window treatments and other less expensive approaches, the lead poisoning rate has dropped to 3.2 percent. That's remarkably low in light of the fact that the rate was as high as 48.5 percent in 1992.

Another more far-reaching approach to the problem will come if the Obama's health program remains on track. The Affordable Care Act sets aside $90 million this year for evidence-based home-visit programs to improve children's health in poor neighborhoods. This should mean putting more health workers into poor communities to help families avoid problems such as lead poisoning. The program is expected to provide outreach services to children up to age 8.

In addition, researchers continue to look at the consequences of lead poisoning beyond health. Studies are being done to determine the indirect influence of lead poisoning on the incidence of crime. Another fertile area for study is the relationship between lead levels and school performance. What's described as a groundbreaking study by Detroit city and school officials found that roughly 58 percent of the students tested had a history of lead poisoning. The study showed that the higher the lead level, the worse the students performed on Michigan's equivalent to the MAP test. St. Louis school officials say they don't keep data on students with histories of lead poisoning.

Robinson says she wishes St. Louis had a law requiring that every home be inspected for lead before pregnant mothers and small children may move in. The city has taken that approach in some high-risk neighborhoods, but money for it is limited.

In the meantime, Robinson is elated by her Larry's progress. She talks about him as if she's speaking of a different boy than the one that caused so much concern two years ago. She says he gradually began to enjoy carrying on imaginary conversations with his teddy bears, wearing the wheels out on his toy cars and trucks and interacting well with children at the child-care center where he's enrolled while she attends ITT Institute. But as she talks about the future, Robinson tempers her optimism with guarded responses, her voice deepening as if the sound is coming from a woman much older than 22.

"I was really hurt when I found out he had lead poisoning and found out later how it might affect him," she says as her hands play with a cell phone.

After a long sigh, she adds: "He's OK right now. But you can't really tell until he gets older. I just hope he doesn't get it again."

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Part Nine: St. Louis University pioneers new approach to preventing lead poisoning

A St. Louis University scholar thinks it's time for cities to refine the way they address lead hazards.

The attack on lead poisoning often begins with the discovery that a child has an elevated level of lead, usually exceeding 10 micrograms for each deciliter of blood. The next step involves a little detective work to find the source of the lead. It usually turns out to be peeling lead-tainted paint and lead dust in an older home. This approach, some say, amounts to making kids the equivalent of canaries in coal mines.

Although many cases of lead in homes still come to the attention of St. Louis health workers after a child has been poisoned, the city's approach has become more refined and proactive over the years. Aside from public awareness campaigns, the city now gives special attention to homes where expectant mothers live and tries to treat those units for lead poisoning before children are born.

But thinking creatively might help cash-strapped cities find more cost-effective ways to find lead before the lead finds the child, says Roger Lewis, an associate professor at St. Louis University's School of Public Health.

Mapping is a key to prevention

Lewis praised St. Louis' program to screen more children and reduce the incidence of lead poisoning. Still, he believes public health workers here and elsewhere might eventually have access to a better system of finding and measuring lead levels in older homes and figuring out where best to spend limited dollars to address the problems.

"The city's efforts to remove lead in housing are guided by existing cases of elevated blood-lead in children," Lewis says. "The goal of our work is to predict where we would find lead and remove it before kids get sick."

Lewis was referring to a $530,000 federal grant that a SLU team got from the Department of Housing and Urban Development to devise better ways to help a city figure out which properties to target for lead removal.

The approach involves property mapping, based on information from multiple databases. These include census data, building division information, real estate records, and state and local health records. Lewis says the city already does some of this work by looking at housing and locations based on zip codes.

Referring to the layers of data his team is using, Lewis says, "What we're doing that's a little out of the box is going to census blocks." Much smaller than a zip code, a census block corresponds, in many cases, to an individual city block. He says the method is like looking at a smaller site through a microscope.

Maximizing dollars; reducing lead exposure

The team hopes to be able to help the city pinpoint where most of the lead exposure is occurring and use information from the statistical model "to establish how much it would cost (to address lead) in that block, which has x amount of lead exposure, as opposed to another block."

The goal, Lewis (right) says is "to maximize our dollars and maximize our reduction of lead at the same time."

What the team has found so far hasn't surprised it.

"If you live in an older home in St. Louis, you're going to be exposed to lead," he says. "If you're unemployed and low income, there's a likelihood that you live in a house with lead. It's a picture that's not surprising for people living in older housing in the rust belt."

Like some other ideas thought to be breakthroughs in an earlier time, lead in paint used to be regarded as a welcome development.

"Lead is a great adhesive," Lewis says. "It makes colors stand out, and we thought it was a great thing. Opening and closing windows and doors (containing lead paint) cause friction, which releases dust, which is ingested by young children."

The drawback, he notes, is that children under age 6 are particularly vulnerable to lead exposure because their brains and central nervous systems are not fully developed. He adds that elevated levels of lead in the blood can result in a variety of health and developmental problems: reduced IQ, learning disabilities, attention deficit disorder, behavioral problems, impaired hearing, stunted growth and kidney damage.

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Part Ten: Race and place matter when it comes to diabetes

 

The genealogy bug first bit Anita Jenkins in the 1970s when she saw the television series "Roots." She takes pride in having traced her family's history at least as far back as antebellum days, and she hopes to turn to DNA to move even further back in time.

In the process of her search, however, she also turned up a family history of diabetes. She mentions this as she stands next to pictures of relatives that line the mantel above the living room fireplace in the family's two-story brick home on the north side. On this day the house is quiet, save for the hum of an air conditioner, on a bright summer afternoon. But she's in a gloomy mood as she introduces the faces in the photographs and talks about how diabetes has affected many of those lives.

 

"My mother had it," she begins, her shoulders sagging. "Her mother and father had it. Her sister had it. All but one of her six brothers had it. My sister has it. My daughter, who's 24, has had it since she was 14, and I've been dealing with it myself for 30 years."

The family suffers from type 2 diabetes. It results from an inability of the body to use insulin, a hormone that helps convert glucose or blood sugar into energy. In recent years, the disease has begun to affect a growing number of whites as well as blacks, health officials say, as Americans become overweight and obese, exercise less and consume unhealthy food.

This is also a pocket book issue. Controlling and preventing the disease would save lives and money. The nation spends an estimated $174 billion a year on diabetes-related care, and as recently as 2006, Missouri was spending $3 billion, a lot of the money going to address complications instead of prevention.

Diabetes hasn't been as devastating for many African Americans as it has for Jenkins, 54. But the disease continues to take a disproportionately heavy toll on blacks. The Missouri Foundation for Health said in a report last year that diabetes was the fifth leading cause of death for African-Americans in Missouri, and ranked as the eighth leading cause for whites.

In 2007, according to the Missouri Department of Health and Senior Services, 387,247 Missourians were estimated to have diabetes:   8.1 percent of all white Missourians; 11.5 percent of all African Americans in Missouri and 11.7 percent of Hispanics in Missouri.

A study by the Department of Health for the city of St. Louis reported a 2007 diabetes mortality rate of 51.1 per 100,000 population of African-Americans in the city, 27.6 per 100,000 of white city residents and 37.4 for all city residents.

AFRICAN-AMERICANS ENDURE MORE AMPUTATIONS

A report by the Dartmouth Atlas Project notes that race and place not only affect the incidence of diabetes but influence treatment. In some instances, changes in a diabetic's blood vessels and nerves can result in ulcers. If they do not heal or result in other complications, doctors might recommend that the limb be amputated. The Dartmouth report noted that African-American Medicare patients lost legs to amputations at a rate nearly five times that of whites. The study suggested that factors beyond the health-care system -- such as poverty and health literacy -- may account for the disparity in amputations.

Like some other diseases, diabetes can be controlled and even prevented, and its causes stem from several factors. Aside from lack of physical activity and being overweight, diabetes is linked to a family history, as Jenkins (right) knows all too well.

The Missouri Foundation for Health report also cites lower levels of vitamin D12 and higher levels of cortisol13, also known as a "stress" hormone, as being among factors affecting the prevalence of diabetes among African Americans. The report says cortisol output increases in relation to stress and contributes to heart disease, as well as diabetes.

ACCESS TO SUPERMARKETS AND EXERCISE FACILITIES MATTERS

The high incidence of diabetes among blacks is one more reminder that where people live makes a big difference in their health. In some instances, residents can help ward off diabetes itself and its side effects through exercise and diet. It's probably no accident that the prevalence of diabetes is higher in zip codes offering consumers the least access to safe public places to exercise and limited access to full-service supermarkets where they might buy fresh fruits and vegetables.

Public health officials point out that having access to these amenities won't necessarily mean all residents would take advantage of them, but they add that giving people convenient access to grocery stores, parks and playgrounds would make them more likely to use them to eat better and exercise more.

As a health risk, diabetes itself isn't the only problem. Equally troubling is the number of serious illnesses it can trigger: heart disease, vision problems and blindness, kidney failure and stroke.

Jenkins, a city worker who handles Medicaid billing issues, has experienced some of these problems. But she isn't one to think of the disease as a family curse. She blames her situation in part on her failure to make healthy choices in her life.

"Having this so long and not taking care of myself the way I should have contributed to my problems," she admits. "I know many things happened because I didn't follow what the doctors told me to do. And I tell my daughter not to go down the same path that I've gone down."

Jenkins thinks the problem for some African Americans boils down in part to culture and habits.

"How things taste is a big issue in my family," she says. "They like fried fish because it tastes better to them than baked fish, which is better for me. When you have people in the house who don't want to eat what you're supposed to, it's extremely hard to eat what I should."

Her problem is complicated by the cost of some medical supplies. She uses a hand-held meter into which she inserts a small plastic strip containing a drop of her blood to test her blood sugar. If the number is too high, it could mean she's consuming too much of the wrong food and may require her to inject insulin into her body.

"I must have a ton of those little meters. They're free, but I can't always afford the strips to use the machine. Sometimes I have to go without prescriptions because I can't afford the co-pays. I have no choice because I still have to keep my lights on, and my gas bill has to be paid."

Her health insurance covers part of the cost of the strips. Depending on which supplier is used, Jenkins says her out-of-pocket cost for the strips is about 50 cents each. They usually come in quantities of 50 or 100. It meant running through a box in less than a month when she was required to test her blood sugar five times a day. Meanwhile, Jenkins said her out-of-pocket costs for a three months supply of pills might run as high as $70. That has dropped somewhat recently since losing weight has meant taking fewer medications, she said.

HELP IS AVAILABLE

Jenkins praises efforts by the St. Louis Diabetes Coalition to show people things they can do to prevent and control the disease through diet and exercise. She adds that people need to find places to exercise even if they live in a north side neighborhood, as she does, where they might feel unsafe taking brisk walks on sidewalks or in parks in that part of town.

Jenkins has found help and support from work-based exercise and weight-loss programs. The city, she says, offers lots of options to promote wellness among its workers. One place she recommends for fellow workers is the gym at the St. Louis Police Academy downtown, which she says workers can use for $10 a month.

At one point, Jenkins decided it was too difficult for her to lose weight, so she underwent gastric surgery, which has helped her lose 135 pounds. It helped her fight diabetes, too, she says.

"Before the surgery, it was five shots of insulin a day. After the surgery, it then went down to one shot a day. I still take pills but nowhere the number that I took before."

The main thing Jenkins has learned about diabetes is to take nothing for granted. That includes limbs and eyesight. Because of the disease, she has had surgery to remove two toes, and she has had eye surgery because she says the disease has affected her vision.

"It's always something," she says of diabetes. "A lot of the time, I just don't feel well."

 

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Part Eleven: Public health workers place their bets on diabetes education

Milton and Leona Scott, both in their late 50s, normally don't spend time at the Four Seasons Hotel adjacent to Lumiere Place Casino in downtown St. Louis. But they were among 250 people who gathered in the hotel's elegant ballroom one Saturday morning last April to learn more about coping with and combating diabetes.

Hosting a free diabetes education program at a 5-diamond hotel may seem unusual, but it's just one of the ways the St. Louis Diabetes Coalition is taking its message out of doctors' offices and to the public. The group also is taking diabetes education to many community-gathering spots, such as churches and coffee shops.

Joan McGinnis, the coalition's director of education, called the hotel "a lovely environment" for the event, which featured a speech by a diabetes educator, questions from the audience and strategies for managing the disease.

McGinnis was particularly elated when hearing that participants, such as the Scotts, learned new things about diabetes even though many have suffered from the disease for several years. Leona Scott appreciated that the group passed out small, magnetic squares, each containing a picture of a food and information on the safe number of grams of carbohydrates a diabetic should consume from the food. Though Scott understands the connection between carbohydrates and her diabetes, she said the magnetic squares made her realize there was an easier and more convenient way to keep track of how many carbs she was consuming.

 

Like the cost of using the hotel site, the material distributed at the session was underwritten in part by Accu-Chek, which makes devices to help consumers test for diabetes. People with diabetes are supposed to consume roughly 60 grams of carbohydrates during each meal.

"One of the problems is that people don't think in terms of serving sizes," McGinnis says. "We need to start with carb counting because people don't understand the concept."

Restaurant serving sizes have increased over the years creating a greater problem.

"Bagels, for example, are larger now," she says. "What you're getting now may be twice the size of what you need, and many contain at least two to three times more grams of carbohydrates than you need."

The coalition is working with Saint Louis University's Center for Outcome Research to broaden the reach of diabetes education. The idea is to empower consumers to make more informed decisions about eating healthy food, being responsible with medications, getting sufficient exercise and communicating with health care providers.

'AN EXPLOSION OF DIABETES'

The coalition's programs are free and open to everyone, but the group is especially interested in reaching people who are clueless about how best to handle a disease that's claiming more victims as Americans get less or no exercise and eat more unhealthy foods.

"There has been an explosion of diabetes," says McGinnis. "Even children are getting Type 2 diabetes at age 10 to 14. It used to be that people would get (Type 2) diabetes when they were in their 40s."

According to the coalition, nearly one in five St. Louisans older than 55 has Type 2 diabetes. African-Americans who are 50 or older are at the highest risk. The diabetes mortality rate for blacks in St. Louis is 51.1 for every 100,000 people, and the white rate is 27.6 for every 100,000.

Even so, those numbers may understate the severity of the problem in many black neighborhoods. For example, in the 63113 zip code, the Ville community where the Scotts live, the rate is 61.8 for every 100,000. The rate in the adjacent 63106 zip code is perhaps the highest in the city -- 71.9 for every 100,000 residents. Several other north side zip codes where the mortality rates are quite high include 63107 (55.6); 63147 (53.5); and 63115 (55.1).

These numbers bring added urgency to the coalition's work. They also offer hope to diabetes educators and diabetics themselves of getting a handle on the problem. The coalition points to research showing that diabetics live healthier and better quality lives when they are taught to manage the disease.

The coalition's work with SLU's Center for Outcome Research is financed by a $99,000 grant from the St. Louis Community/University Health Research Partnership. Set up in 2009, the partnership focuses on research into diabetes and other health problems. The partnership, assisted by the Regional Health Commission, is supported by $1.5 million in funds from SLU, Washington University, and BJC HealthCare. The Missouri Foundation for Health also helps to finance other area initiatives to fight diabetes.

Thomas Burroughs, principal investigator for the partnership's program, says the diabetes outreach project "dives into self-testing blood glucose levels, planning diet and exercise, and communicating honestly and effectively with health-care providers" about diabetes.

MANY HAVE NEVER PARTICIPATED

Though Type 2 diabetes is widespread, the partnership says a shortage of education programs prevents many from taking control of their diabetes. The coalition says that 49 percent of St. Louisans with diabetes, or an estimated 75,000 people, have never taken a class to learn how to manage the illness.

In addition, McGinnis points to several barriers that thwart Type 2 diabetics from getting help, including lack of insurance or limited coverage. Others, she says, don't get the education because their jobs prevent them from taking off to participate. She also says some are impeded because they do not get the support and encouragement to understand how diabetes, a chronic disease, can affect their lives.

"We've designed our program to address all of these barriers," she says. "Through this project, experienced diabetes nurse educators and nutritionists will be available to provide individual consultations in convenient nearby locations."

Eric Armbrecht (right), assistant professor of internal medicine and health management and policy at SLU, says the project builds on progress the coalition and others have made in addressing diabetes over the years.

"The coalition has a strong tradition of using new approaches to engage and educate people with diabetes," he says. "We believe our university-community collaboration can be a powerful force in improving the health of St. Louisians with diabetes."

Aside from these issues are others that can make a difference. Public health workers here and nationwide have called attention to how safe sidewalks, parks, reliable public transportation and access to fresh fruits and vegetables can reduce the severity of diabetes.

One study by Amy Auchincloss of Drexel University in Philadelphia showed that people with these options were 38 percent less likely to develop diabetes. Her research covered 2,285 adults, between the ages of 45 and 84, based on information about physical activity, weight, diet and blood sugar levels between 2000 and 2002.

McGinnis also suggests that some of the responsibility should be placed on health-care providers who may not be getting across to patients the importance of diabetes education.

"You have to work with people to help them understand that you need it," she says.

Diabetes education is a way to help patients ask their doctors the right questions.

"A lot of people think of doctors as authoritarian, perhaps," McGinnis says. "You have to ask them what can you do to help yourself improve your diabetes care. A lot of people will not do that."

 

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Part Twelve: Program for treating teens with STDs hits the SPOT

The 12-story building between Powell Symphony Hall and the Third Baptist Church in midtown seemed like an odd place to house the city's main clinic for treating sexually transmitted diseases. Yet, for a long time, some city residents wishing to get help, counseling or advice for an STD had few options bsides visiting the public clinic on the second floor of the building at 634 North Grand.

Some city officials now concede that it was perhaps unwise to use the North Grand site because the high-traffic location probably discouraged some people from seeking help out of concern about their privacy.

"You walked into the building after 9/11, and security would ask you where you were going. If you said second floor, they knew what you had," says city Health Commissioner Melba Moore (right). "We wanted to make things better by doing a better job. So, we felt we'd be better off putting the services in the community."

The decisions to shift STD clinical services to community settings and focus on evidence-based approaches are among reasons city health officials say they are making headway in reducing STD rates that have been among the nation's highest.

The first proof came with the latest numbers from the Centers for Disease Control and Prevention. For a decade, the city has routinely placed near the top in gonorrhea and chlamydia infections. But the new data, released Tuesday, show that St. Louis had lower rates for gonorrhea and syphilis in 2009 than in 2008, and saw an easing in the rise of chlamydia infections as well. The city still ranked second in chlamydia, but the rate hadn't risen as fast as it did in previous years.

Pamela Rice Walker (right), the city's interim health director, said in a statement Tuesday that the drop showed that "parents and the community of health providers have made it a priority to reduce the number of STDs among our youth. This report shows that the things we are doing are working, but we must remain vigilant."

WORKING WITH TEENS

Walker was referring to a range of city, county and nongovernmental programs that have increased testing and treatment for STDs and helped to reduce infection rates. There also have been new approaches to addressing STD rates.

One successful approach is called SPOT -- Supporting Positive Opportunities with Teens. Its headquarters are at 4169 Laclede Ave., a site that's a far cry from the building on North Grand. SPOT is a friendly, youth-focused place where young people can drop in for numerous services that have nothing to do with STDs.

Those make it a more inviting site for youngsters to congregate and seek help, says Dr. Katie Plax (right), medical director of SPOT.

"We have youths staffing our front desk. It makes people feel comfortable when they walk in. They're being greeted by someone in their age group. It lets them know 'You can trust the services because I do.' "

Like Moore, Plax says new approaches like SPOT have helped the city lure more young people into seeking help. Plax says that's important because young people, mainly between the ages of 15 and 19, have been leading the way in the rise in infection rates for gonorrhea and chlamydia.

 

"We know a lot of barriers got in the way," Plax says. "There were costs and insurance or lack thereof, transportation to get to where services were and the services might not all be together. It meant going one place to see a doctor, another to get lab tests, still another to pick up medications for treatment. And there was the worry among a lot of young people about the confidentiality of their health information."

She says, "We were trying to work against those barriers by making services free and having all the things in one place. Now you can see your doctor, get your testing done and get treatment all under one roof."

In addition, epidemiologist Kelly Zara says, treatment options have helped to reduce infection rates.

"People are now able to get one-dose treatment for gonorrhea," Zara says. "In the past, if someone got medication to be taken over 10 days, not everyone would take all the medicine. They might take it for two days and stop. But if they don't have to be compliant for 10 days, hopefully now, they're not going to be infectious to other people."

Although everyone agrees that the city needs to do more, Zara (right) says the city seems headed in the right direciton.

"I'm encouraged because, although chlamydia is still a problem, it's a problem nationally. It's not just something we're dealing with here. Everybody's dealing with it, and we've kept the increase small," she said.

"The gonorrhea rate is encouraging, too. We've been dropping since 2006. In terms of syphilis, we're doing pretty well. We've had a drop in cases since 2008 while nationally the rate for the number of syphilis cases has gone up. So that's good. We're not following the trends of going up," added Zara.

Places like SPOT make diagnosis and treatment easier, she says, "because it's a place where they're comfortable. They are around other people their own age. They don't have to worry about someone from their neighborhood walking in the door and seeing them at a clinic and learn what they are doing."

SPOT offers a lot more. Youngsters can drop in for a free snack, take a shower, do their laundry, work on a computer, watch TV and get lots of free health services, including STD and HIV testing, pregnancy testing, contraception, pap smears and referrals for other health needs.

YET STILL MORE IS NEEDED

Still, Plax and others don't deny the holes in the city's safety net. One problem, she says, is funding. It's a factor cited by others who note the city's public health budget has been declining.

In some other cities, Plax notes, "there are lots of folks going out to let partners know they should be tested and treated for an exposure to an STD. If you don't have money to hire those people, that can make a difference."

In addition, she says, there is more "need for free comprehensive sex education in schools to reach people and let them know the facts."

With SPOT, she says the city has a model that allows it to have youths "working in partnership with us to tell us what it is they need. Also having free services and having people who love to work with young people make a difference."

Many health providers agree that one reason the city probably saw a spike in its STD rates was because it made a commitment to expand testing.

"As we see more access to testing and more people treated, we should also see the numbers come down," Plax says.

That apparently is what's happening with the city's rates. She notes that a lot more testing also is being done by others, including Planned Parenthood and health clinics in St. Louis and St. Louis County. SPOT's funding comes from several sources, including the city, the Missouri Foundation for Health, BJC Healthcare, St. Louis Children's Hospital Foundation and Washington University. St. Louis also has its own set of youth-focused programs to address STDs.

"I think one thing we shouldn't forget is that we should ask youths directly for their help and ideas about what solutions they see to the problems," Plax says. "Chances are they will give us great advice. I don't think we can do it without them."

 

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Part Thirteen: Street smarts and training aid in battle against sexually transmitted diseases

He got his education in the streets, and she got hers at the University of Texas School of Public Health. She left a job at the Centers for Disease Control and Prevention in Atlanta to join the St. Louis Health Department. He also got a job in the department after he decided to turn his life around and focus on encouraging inner city youngsters to go straight and steer clear of at-risk behavior.

In time, this unlikely team of Brandii Mayes and Aaron Morris, both under 30, would become the most visible faces in the city Health Department's fight against sexually transmitted diseases. They are part of the department's first-ever youth component to address STDs and were brought on board when the STD rates in St. Louis were among the nation's highest.

Relying on a combination of academic training and street smarts, the two established the Body and Soul project to educate young people about STD prevention and intervention. At the time that the Body and Soul project began in 2006, nearly 72 percent of chlamydia cases and over 60 percent of gonorrhea cases in St. Louis involved city residents in the 15-24 age group. City health officials said the data showed that nearly 94 percent of chlamydia cases, 96 percent of gonorrhea cases, and 93 percent of syphilis cases involved African Americans. The CDC says the problems can be traced to larger problems, such as limited access to comprehensive physical and mental health care, the consequences of poverty, ignorance among young people about risks associated with sexual activity and ignorance as well about treatment options.

STDS AFFECT ALL OF US

The STD problem may seem like an issue of little consequence to anyone except those who engage in risky sexual behavior. But it's a public health problem that indirectly affects everybody, consuming about $15 billion nationwide in medical expenses each year, the CDC says. It adds that some women victims face related illnesses, such as cervical cancer, infertility and ectopic pregnancy.

Body and Soul is just one city approach to STDs among young people. Another is a drop-in clinic, called the SPOT, or Supporting Positive Opportunities with Teens, part of a collaboration with BJC Health Care. In addition, the city has turned to more aggressive testing and screening at unusual sites, such as jails and juvenile detention facilities, as well as mobile clinics, and free, walk-in STD clinical services at ConnectCare. These proactive attacks seem to be paying off. For a decade, the city has routinely placed near the top in gonorrhea and chlamydia infections. But new CDC data, released last week, show that St. Louis had lower rates for gonorrhea and syphilis in 2009 than in 2008, and saw an easing in the rise of chlamydia infections as well. The city still ranked second in the nation in chlamydia, but the rate hadn't risen as fast as it did in previous years.

Allowing young adults to take a greater role educating other youngsters about STD issues began when the city set up YEAH, which stands for Youth Empowerment Advocates for Health. Through YEAH, Mayes and Morris created the Body and Soul project.

music moves mindS

Their challenge had been to come up with a program that would hold the attention of inner city blacks long enough to get across messages about sexual health.

Mayes says, "We wanted to put together something that teaches black teens that's not only informative but fun, that's exciting with an entertainment component. While we always have a message, we don't just talk bout STDs."

She adds that the written word is losing its impact and that youngsters nowadays are "very into technology. They're into music. They watch a lot of videos. You might give them a piece of paper with information and they might look at it and throw it on the ground. But they're very receptive to music. So we always try to incorporate music in some way. We also give out T-shirts and prizes."

The Body and Soul name came to Morris because he and Mayes wanted to stress that the fight against STDs not only was about protecting the body but using the mind to help make good choices about sex and produce positive outcomes.

Body and Soul quickly organized projects at St. Louis Community College at Forest Park. The youth-oriented events included poetry, rapping, music and other engaging ways to boost awareness about STDs, the need for abstinence and some of the consequences of risky behavior. About 200 people, including 60 parents, turned out for the event, and about 60 young people signed pledges to take the sexual health message to others in the community.

reaching people 'where they are'

Mayes had been content working at the CDC in Atlanta before coming to St. Louis. But two of the city's top health officials -- interim Health Director Pamela Rice Walker and Health Commissioner Melba R. Moore -- offered her a job and a challenge to be part of the first youth component in the city Health Department.

"We've now gone to churches. We've gone to high schools. We've gone to community centers. We've gone to any place we could with an entertaining message," Mayes (right) says.

"You know, when we started working with churches, I was concerned about taking the message about STDs to the churches, but some of the clergy have been really responsive."

Morris adds, "Sometimes, we go in and they'll give us restrictions, asking, for example, that we not bring condoms. We're OK with that."

Mayes adds that "you have to reach people where they are. That's what's important. We always encourage abstinence as the only way to stay STD free. But we encourage protection as a must if you are engaging in sexual activity."

dealing with emotion and ego

The two have learned lessons of their own about how teens and young adults view sex. For girls, Mayes says, "I've learned that it's not just about sex and condom

s. It's often about family and loneliness, a desire to be loved. We listen as much as we talk during these sessions. It's not scare tactics that a lot of other people might try to use, and we think our approach is working."

Morris adds that he has had to shatter some egos among the boys. One thing he hears them talk about is needing to use the largest condom they can find.

"They might say, 'Yeah, man, we're Mags,' " Morris (right) says, meaning nothing smaller than a Trojan Magnum condom will fit.

To show them they don't need the size their egos might suggest, Morris slips a less expensive condom onto his hand and part of his wrist. He says some of the young men are surprised by what they see, not realizing that a condom can be stretched that much.

"I tell them, 'You thought you needed a Magnum, but you're really just being charged more for your ego.' You know what I'm saying?"

He says the team comes across a lot of other myths, including one about young men using ear wax to determine if a partner is clean.

"Supposedly you dig some wax out of your ear and place it in her opening and if she jumps, it means she's dirty," Morris says. "We have to remove those kinds of myths and give people the facts. Another one is that brothers can strap up twice (strap on two condoms) for protection. We have to

educate them to the fact that using two condoms can lead to friction upon friction, and that can lead to breakage."

Morris worked his way from the streets to participation in the city's old gang abatement program, and he is now supervisor of the YEAH Team. He says he is able to reach a lot of people because he understands youth better than most.

"In the African-American community, it's not just about testing," he says. "Getting tested is one thing, but how to prevent it is another. I've seen a situation, for example, where a young mother who is only 19 years old, addicted to heroin and doesn't have a lot of skills. She has become lazy because of her drug use and is willing to have sex to get another high."

Morris adds, "My reaction to cases like that is always emotional because I'm a former gang member and a former drug dealer. So it's a touchy issue for me. But I have to show people what we can do to help them, you know."

Mayes adds a word of caution. While gratified that Body and Soul seems to be making a difference, she says, "I don't want to make it seem as though, you know, we have come in and saved the day."

Which is her way of saying the city still has a lot of work to do to get STDs under control.

 

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Part fourteen: New sexual-health program focuses on girls in foster care

Health professionals in St. Louis are paying closer attention to the sexual health of girls in foster care because data show that about half of them become pregnant or give birth while they are still teens, according to Dr. Katie Plax, a specialist in adolescent medicine at Washington University.

 

 

 

Plax (left) leads the Pregnancy Prevention Initiative, which will address pregnancies and sexually transmitted diseases among foster care girls in St. Louis and St. Louis County. The program should be fully operational by next fall. She says the pregnancy rate among these girls is comparable to numbers throughout the country. But the rate is still alarmingly high in light of St. Louis' overall teen pregnancy rate of 17 percent. The national average is 12 percent.

 Plax says the girls will get medical services at the SPOT, Supporting Positive Opportunities with Teens, a drop-in teen health center where she is medical director. The center offers young men and women help with a range of issues, including sexually transmitted diseases (STDs). In some cases, Plax says, girls in foster care were found to have been sexually or physically abused.

"Ongoing medical care was a huge issue," Plax said. "Some of these kids often have not seen a doctor for years, or even received checkups, or even had their eyes checked when they need glasses to read and succeed in school. Those are some common occurrences that we see."

Plax says the program would serve about 600 teens in foster care or aging out of foster care in St. Louis and St. Louis County.

"We will use a proven program with these young women to help them prevent unwanted pregnancies and reduce the risk of contracting sexually transmitted diseases," Plax says.

Health educators at the SPOT will use what's known as a safer sex intervention model, Plax says. It's a three-part program designed to increase condom use, reduce risky sexual behaviors and prevent recurrent STDs among female adolescents. The girls also will also be allowed to take part in the contraceptive choice project, a Washington University research study that involves free contraception. The girls also will all receive comprehensive medical exams to determine their health needs.

"Kids who go into this (safer sex) program tend to have fewer partners and fewer STDs," she says. "I feel that we're using the best evidence to affect the numbers. We're really determined to reach out to make it better for youths by giving them better health care and health advice."

 

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Part fifteen: Safer neighborhoods can lead to leaner bodies

With its two-story brick and siding homes, black metal mail boxes on the lawns, and sturdy sidewalks out front, the quiet stretch of St. Ferdinand, west of North Vandeventer, looks more like a slice of suburbia than a piece of north St. Louis. In a part of town where the quiet of some neighborhoods is interrupted by occasional gunfire, this street offers a safe haven for youngsters like Derriyon Hobbs.

 A chubby kid with a ready smile, Hobbs often spent his summer days pedaling his bike up and down St. Ferdinand without the watchful eye of his mother, Sherita Calvin. Both are grateful to have come to a neighborhood where people walk at their leisure rather than at their peril.

"I used to live on a very busy part of North Kingshighway," Calvin says. "It was in a bad crime neighborhood. During the day we weren't able to sit outside or take a walk because we were afraid someone would try to mug us, hurt us. We were afraid to walk even to the corner store. Now I can not only walk to the corner but walk three or four blocks."

That amount of walking is making a big difference to a mom and son for whom the big-screen television in the family living room used to be the equivalent of an after-dinner companion.

"We used to eat every evening and then just sit on the couch and watch television," Calvin says of the days when meals meant foods heavy on fat and sugar.

"I knew they were bad for me, but it was a habit that I had," she says.

obesity is not just a family matter

Like some other kids exposed to fatty and sugary foods, Derriyon, an 8-year-old third grader at a charter school, is a bit flabby around the waist. He weighed 114 pounds, and he was struggling to drop to a double-digit number.

Obesity among children used to be regarded as a private family matter rather than a social issue. At least one in every five Missouri children between the ages of 5 and 11 is estimated to be overweight. While the problem is common across racial lines, research shows that geography can play a role. Overweight children tend to be more common in communities with fewer full-service grocery stores, fewer safe and well-maintained parks that encourage physical activity, and fewer sidewalks on which children like Derriyon can exercise indirectly by riding their bikes and skateboards.

Though some argue that parents must bear the responsibility for the health of their children, the fact is that every Missourian already is footing the bill for obesity among all age groups. About five years ago, the state reported that $1.6 billion was being spent annually on obesity-attributed medical expenses, such as treating diabetes, heart disease, arthritis and certain types of cancer. Put another way, the state and the nation could save billions of dollars by controlling obesity because it causes or aggravates many illnesses.

"Our health-care costs have grown along with our waist lines," said Jeff Levi, executive director of Trust for America's Health.

That's why youngsters like Derriyon get more pep talks about obesity from many sources, including First Lady Michelle Obama. In addition, many public health workers are at work on projects tackling childhood obesity.

One is a free Washington University program called COMPASS. That's an acronym for Comprehensive Maintenance Program to Achieve Sustained Success. It seeks to reduce childhood obesity by working with children like Derriyon and their parents. Both a child and at least one parent must be overweight to take part in the one-year COMPASS program. Because Calvin, 40, is overweight, she has joined her son as a COMPASS participant.

focusing on exercise and healthy choices

Instead of relying on medicine, COMPASS focuses on helping enrollees learn to incorporate exercise into daily routines and to eat healthier meals. Dorothy J. Van Buren, an assistant research professor at Washington University, says COMPASS requires one or both parents to participate with their overweight youngster because adults can be the key to helping children shed pounds. By learning to make healthy food choices for themselves, parents can indirectly influence the behavior of their youngsters, she says.

"Parents are the gatekeeper for healthy behavior at home," Van Buren says. "It's much easier to help children who are overweight if their parents are involved."

Hobbs says the family still eats many of the same foods but that the program has taught her to bake meats to reduce the fat, use salt substitutes and coat her cooking pans with a spray rather than oil.

Derriyon initially had doubts when his mother encouraged him to enroll in COMPASS.

"I was afraid I wouldn't lose weight because I was in the habit of eating junk food," he says.

Calvin says she now sees a big difference in her son's physical activity level.

"I'm very proud of him for sticking to this program. He was kind of leery about being in a program where people tell him what he can and can't eat. The big difference I see in him now is that I don't have to make him ride his bike or exercise. He just does it."

As tough as losing weight might be, helping kids keep the pounds off can be even more challenging, Van Buren concedes. She notes that people who lose weight tend to regain it within a year. But she says COMPASS gives participants access to health specialists who offer individual plans that help families work on both eating habits and physical activity.

Missouri is in the middle of the obesity pack

In spite of many efforts to attack and control diabetes, 31 percent of Missouri youngsters in the 10-17 category are overweight, according to a report last year by the Trust for America's Health and the Robert Wood Johnson Foundation. The number means Missouri ranked 23rd nationally in overweight youngsters.

Mississippi had the highest rate of adult obesity at 32.5 percent, making it the fifth year in a row that the state topped the list.

Whatever its ranking, St. Louis or the state can't afford to wait to tackle obesity by changing the built environment, says Althea Albert-Santiago, food service director for St. Louis Public Schools. She notes that meals served at schools are the only chance some youngsters have to consume a balanced diet. That fact, she says, is among reasons the district is doing more to scrap certain foods, such as fried chicken and French fries, in favor of baked items. Schools now offer whole-wheat pizzas, along with fresh fruits and green and orange vegetables several times a week. In addition, she says the district has collaborated with other groups to bring in chefs and celebrities, including pro athletes, to talk about health and show them how to prepare snacks simple enough for them to make at home.

"Hopefully," she says, "they won't grow up and become obese because they have been taught at the ground level about the need for eating healthy meals."

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Part sixteen: A 'Healthy Start' for infants can make a huge difference

Click flash ... click click, flash flash ... clickflashclickflashclickflash ...

The sharp sounds and bursts of light come from a disposable camera in the hands of Carolyn Dickerson. When Healthy Start, a maternal health group, gave cameras to her and other at-risk pregnant or postpartum women, they told the women to show how the world looked through their eyes. The organization might have been a little surprised by some of the results.

Granted, the women came back with some images of distressing sights common in inner-city neighborhoods: vermin-infested trash, menacing-looking vacant buildings and boarded-up stores. But Dickerson and a few others captured sights that said less about their immediate surroundings and more about a promising future they wanted for themselves and their babies.

Dickerson raises her camera upward. Click, flash. She captures a mostly blue sky with not a dark cloud in sight. She would later write of the photo's calming effect, saying it represented being "content, cool... You been at work all day, then you're at home by yourself, and see this."

Now she's in West County. Click, flash. Her lens picks up a vast sweep of green grass beyond which stand trees and beyond that a blue sky. Under this photo, she writes "no trash! ... This is the scene I would like to see in my neighborhood instead of trash; bars on my windows and doors to feel safe."

A hopeful outlook like hers is what nurses and outreach mothers try to instill in women in the Healthy Start project, a partnership between the Maternal Child and Family Health Coalition and the Nurses for Newborns Foundation. The project aims to reduce infant mortality and provide parents with the means to give their infants healthy starts in life.

The photography project was part of a PhotoVoice Empowerment Initiative in which the mothers were asked to create a window on their neighborhoods, their needs and perhaps illuminate why health and prosperity remain so elusive.

Kendra Copanas, executive director of the Maternal Child Health Coalition, is proud of the efforts to bring hope to women who otherwise might have none.

"The nurses and community outreach mothers establish positive relationships with program participants," Copanas says. "It is through this connection that we are best able to help women set and achieve goals for improving their family's quality of life."

Dickerson says, "Being part of Healthy Start was like a dream come true to me." Her child, Isaac, was born premature, had to remain in the hospital a short time after birth, and weighed 4 pounds, 13 ounces, which placed him in the low birth weight range. But Dickerson notes that Healthy Start worked with her to make sure Isaac, now age 4, would lead a healthy life.

Through the teamwork, the child became one more saved from a potentially early death in a city where infant mortality is high.

grim statistics

Infant mortality refers to the death of an infant before his or her first birthday. The overall rate for the city in 2007 was 11.9 per 1,000 live births. For blacks during that period, the rate was 15.8 per 1,000 live births, which was in line with the average national  rate of 15.4 for blacks. For whites in St. Louis, the rate was 5.7 per 1,000, the same rate for whites nationally.

 

       

The findings suggest that health outcomes tend to be influenced by where people live, as data from Vision for Children at Risk show. In many zip codes where the infant mortality rates are high, a relatively large percentage of women got inadequate prenatal care or no care, according to Vision's 2009 report. In the three zip codes targeted in the Beacon's review of health disparities -- 63106, 63107 and 63113 -- the percentage of women getting inadequate or no prenatal care ranged from 25 percent to 39 percent, Vision's data show.

These inadequacies explain why Maternal and Child Health and Nurses for Newborns are so crucial. A recent evaluation found that women in Healthy Start showed a vast improvement over the norm. They had 54 percent lower rates of low birth weight births, 46 percent lower pre-term deliveries and 44 percent higher rates of adequate prenatal care.

Experts have yet to fully understand the many factors that contribute to infant mortality, says Copanas. "Our members and parents have directed us to focus on social determinants: lack of quality education, single parent homes, inadequate and unhealthy housing, inadequate transportation, violence and crime in neighborhoods," she said. They also point to cognitive differences in children who grow up in violent communities and feel unsafe all the time.

Copanas also says segregation remains an issue and a health-related factor in the metropolitan area. She points to one study listing St. Louis as being among 22 so-called hyper-segregated cities – those in which blacks suffer high racial isolation in terms of housing and education. She said one study showed higher rates of pre-term deliveries and a higher rate of disparities in birth outcomes in cities having high levels of racial segregation. The latest federal population statistics released Tuesday suggested that the move to reduce segregation is at a standstill. St. Louis area ranked 9th among the nation’s 25 most segregated metopolitan areas, with no major change in the situation in about two decades, according to the 2009 U.S. Census data.

The Maternal Child and Family Health Coalition covers three zip codes -- 63113 and 63120 on the north side and 63136 in the Jennings area -- and serves about 100 clients at a time. But because of the turnover, the program has served about 300 women and children through a $550,000 federal grant. A client is either a pregnant mother or a mother with a child up to age 2. The number served is relatively small, Copanas acknowledges, noting that roughly 1,300 babies are born a year in the three zip codes alone. It's not unreasonable to assume that the zip codes include many other at-risk families that could use Healthy Start.

social consequences are vast

Copanas says infant mortality is an important issue because it represents a measurement of a community's overall well-being. Others, like Dr. Corrine Walentik, a neonatologist at SSM Cardinal Glennon Children's Medical Center, add that the issue is important to everyone in a very practical sense. Assuring that women have healthy pregnancies is "much cheaper than having the consequences of babies dying or being born prematurely and having complications. We know it costs more to have babies in neonatal units, and the hospital stays for premature babies are much more expensive than for full-term babies."

Add to those costs, she says, the fact that some premature infants "are less likely to develop their full potential, affecting IQ and things like that. This is also the workforce issue of the future."

Healthy Start's goal is to find and place as many at-risk women as it can in prenatal care. Its work includes mentoring, nutrition, housing and psychological support.

Both Copanas and Walentik say high-tech medicine has done about all it can to lower infant mortality. The challenge now is to do more outreach through programs like Healthy Start to help women better prepare for a pregnancy.

"What we're dealing with now," says Walentik, "is a problem pretty much related to poverty, and it's part of the social determinants of health. So you're not going to fix the problem just with prenatal care."

Ideally, the experts say, the process should begin even before women become pregnant. The problem, however, is that some women don't get early prenatal care, let alone good health care before a pregnancy.

"So if there was a condition that could have been fixed or improved before the woman became pregnant, it didn't happen," Walentik says. "You have to be healthy; you have to have good nutrition before you're pregnant and you have to have less stress factors."

These are conditions missing in the lives of many urban women. A lot of women that "we take care of in the city are unemployed or underemployed," Walentik says. "They may not be sure where their next meal is. They may be homeless or living with many other people in the family. All of that produces an awful lot of stress and not having a healthy pregnancy."

She also notes that some mothers are obese and might have type 2 diabetes and other chronic illnesses that can produce major problems during pregnancies.

making a difference

Copanas, who has been executive director since 2004, adds that programs like Healthy Start are not new but that funding for the programs eroded over time.

"We are now trying to rebuild what used to be a more comprehensive system of public health," she says.

She calls her job a "passion and I just stumbled into this field." That passion was fueled by rewarding work of improving the health of babies in the Bootheel by helping to start up a program there to reduce infant mortality.

"It clicked for me," she says, adding that her most gratifying experience is seeing a connection between public health programs and the people served. She tells the story of one client who was unable to read and was often defensive to cover up her illiteracy. One day, she was faced with a challenge when a friend went into labor prematurely, Copanas says.

"Despite her lack of reading ability, she delivered her friend's baby in crisis. She called 911 and began using all the information she had acquired through a video her (Healthy Start) home visitor had showed her."

By the time help arrived, the woman had "delivered the baby and cut the umbilical cord. Because of her actions, the baby and the new mom are doing well."

Copanas points to that incident as one of the rewarding part of "building programs that make a difference in women's lives."

On the disappointing side, she mentions a couple of Healthy Start cases "where, in spite of the best efforts of everybody, the baby still died. So we realize we're not going to help everybody. Fortunately, it doesn't happen very often."

 

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Part seventeen: 'Outreach moms' forge a bond with at-risk mothers

So-called "outreach moms" are among the most important links in the Healthy Start program for pregnant women, infants and families. Their work isn't easy; each of the three moms is expected to be available 24/7 to respond to problems that might crop up among at-risk women.

Genetta Robinson, 32, is one such mom. Recently, she got a call from a mother out of money and nearly out of baby formula. The Robinson family includes two small children. Robinson didn't think twice about delivering some formula, knowing that doing so might make a big difference in a healthy outcome for the infant and peace of mind for the mother.

"We try to mentor them like a mother would," says Robinson, who serves as a surrogate mom for about 30 women. The program works with mothers and children up to age 2.

"It works well. They communicate with us and sometimes feel more comfortable speaking to us than they might feel talking to the nurse," Robinson says.

An example, Robinson says, involved a mother who confided in her that she was pregnant again. Robinson was glad that the woman was willing to confide in someone since the admission helped Healthy Start get her the care she needed. Without being judgmental, Robinson said she also encouraged her to inform the nurse, too.

finding common ground

"They might feel more comfortable talking to me initially because I'm like a peer mom," Robinson says. "A lot of them have parents but may not have good relationships with them, don't feel close. So it's good for the young mothers to have someone to talk to. It makes a big difference. I have a 1 year old and a 4 year old, so we can talk about some of the things that I have done with my babies."

Healthy Start is a partnership between the Maternal, Child and Family Health Coalition of St. Louis and the Nurses for Newborn Foundation. Kendra Copanas, executive director of the Maternal Health Coalition, says one key is to be ready to take in pregnant women on short notice.

"Women enter the program with many needs and at different states of readiness for help," she says. "If they've had experiences with child protective services, if they have been abused or didn't have a strong loving family growing up, they may not be ready to open up to the home visitor."

She says some may be reluctant because of problems in their lives, such as drug or alcohol addiction, domestic violence or sexually transmitted diseases. This contact is crucial because Healthy Start tries to enroll women as early in their pregnancies as possible and work with them until the child reaches age 2.

"The programs need to be ready and accessible to women when they are ready for help."

On the other hand, she says, lots of women also seek out Healthy Start and welcome nurses and outreach moms into their lives.

It's through such connections, Copanas says, that Healthy Start is able to help women set and achieve goals. It's also an important key to reducing infant mortality, she says.

Still, one big challenge is to help the mothers overcome resistance to the good advice offered by Healthy Start nurses and outreach moms.

One example involves sleeping practices for infants. Mothers are encouraged to put infants to sleep in their own beds. But Copanas mentions one nurse who noticed that a mother who nonetheless continued to share her bed with her infant. Later, Copanas says, a program nurse "learned that there were so many bugs in the house that the mother felt the baby was more protected sleeping with her."

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Part eighteen: Doctor-patient communication gap can cost lives and increase health-care costs

Enisa Muratovic didn't quite know what to make of the charade-like sight of her son's pediatrician looking at her and banging on a lead pipe in the examination room.

The scene turned out to be the doctor's well-meaning but futile attempt to inform Muratovic that her son had an elevated level of lead in his blood. But the incident was bewildering to Muratovic, a Bosnian immigrant who spoke limited English at the time. She left the doctor's office still unsure what was wrong with her baby.

"I felt confused and afraid," she said.

The incident, mentioned in a Health Literacy Missouri newsletter, addresses a communication gap involving a Bosnian family. But the doctor-patient communication gap in St. Louis is probably more pronounced among blacks on the north side, where health outcomes are worse than in any other part of the city.

Health literacy is the degree to which people can get and understand basic health information to make decisions and take appropriate action, explains Arthur Culbert. He is president and chief executive officer of Health Literacy Missouri, a year-old nonprofit funded by the Missouri Foundation for Health.

It helps, he and others say, to present the information in language that is familiar to patients.

"There is a real need for providers to understand patients, but also for patients to ask doctors the right questions and engage in healthy behavior," Culbert says.

blacks bear the greatest burden

In Missouri, Culbert says, an estimated 1.6 million adults are affected by health literacy. When patients misunderstand the doctor or the written instructions or the labels on medicine bottles, problems result. Health illiteracy can lead to higher use of emergency rooms, errors in medications, less patient follow through with prescribed treatment and less focus on preventive care, he says. And, in some cases, Culbert adds, "low health literacy can be a matter of life and death." That's also the view of the American Medical Association. It points to low health literacy as a stronger predictor of a person's health than age, income, employment status, education level and race.

Beyond the human cost, Culbert says, is the fact that low health literacy is thought to add at least $3 billion in avoidable costs to medical care in Missouri each year.

The problem is particularly acute with black patients. Studies show that they receive fewer medical services or too many of the wrong services than other groups. One Dartmouth University study found, for example, that black Missourians with diabetes were four times as likely to have a limb amputated than whites. The black patients also were less likely than whites to receive annual hemoglobin A1c testing for diabetes. The AMA notes that the disparity involves race and goes beyond it. The medical group apologized for once excluding black physicians from its membership and has begun offering continuing medical education courses to make doctors more culturally sensitive about certain habits and practices.

One AMA course points out instances in which doctors offered more care options to white patients than to blacks and Hispanics, including treatments for heart disease, such as catheterization, angioplasty and bypass surgery. Doctors in the AMA's continuing medical education course were also told that only 49 percent of Asian women got Pap tests, compared to the national average of 64 percent.

barnes-jewish hospital takes the lead

Barnes-Jewish Hospital is the area's only health system to focus on health literacy and health disparity throughout its health-care system. The woman leading the program is Brenda Battle. During a presentation last summer at a seminar in the Loop, she acknowledged that some doctors and other health professionals were lukewarm to the program at the start. But she says many are now embracing it as they understand that the goal is to improve health quality and outcomes.

Her presentation placed much emphasis on doctor-patient communication, noting that any mismatch between what the physician says and what the patient hears can hurt the provision of health care.

She also talked about the need to break down medical jargon into terms more familiar to the general public. A few examples: analgesic means painkiller; carcinoma means cancer; benign means not cancerous; lipids means fats in the blood; and referral means sending the patient to another doctor. She also discussed how patients can get more out of sessions with their doctors by coming prepared to explain their condition and get answers. She said it helps when patients explain:

• Why they are seeking help
• What might have caused the condition and when
• The severity of the condition
• Treatments already tried
• Expectations from the treatment as well as the treatment that they think they should receive.

Putting patient care in context

Numerous groups have taken a variety of approaches to empowering patients and sensitizing providers. One group is the Maternal, Child and Family Health Coalition, which partners with the Nurses for Newborn Foundation to give youngsters healthy starts in life. Kendra Copanas, executive director of the Maternal Child Health Coalition, says it's important to give health-care providers a "snapshot view of their patient's world." The group sponsors a tour through neighborhoods served by the Healthy Start program. The tour, she says, can help a provider understand the context, for example, when seeing "a patient repeatedly in the hospital for asthma attacks. If you have vacant buildings next door to your home, you can't control the rodents and the roaches, which are asthma triggers."

A more intense approach to health literacy is offered through the Inclusion Institute for Healthcare, a program sponsored by the National Conference for Community & Justice of Metropolitan St. Louis. NCCJ's executive director, Denise M. DeCou, says this issue has emerged because socially and economically disadvantaged people were discouraged by their encounters with health-care professionals. She adds that part of the problem is that doctors use jargon. "If people go to a doctor or health center and the information that they are getting is not information that they understand, they may tend to not go."

The program has touched only a small portion of providers, about 85 with a goal of 100.

getting beyond labels

David J. Martineau, NCCJ's program manager, says the institute's approach can help build a network of workers committed to changing the "dynamics that perpetuate health disparities."

In a typical retreat session, participants are seated in a circle and discuss a range of issues, such as stereotypes that some providers might have about patients. The issue might focus less on race than on behavior associated with a patient's class, usually low income.

One example of the unconscious bias, he says, involves a patient who might be a familiar face in the ER. Martineau says the patient's chart might have the initials "FF" next to the patient's name, meaning he's a frequent flyer or someone who "comes back chronically, who came back without following orders."

He says the frequent flyer is just one of many code names or labels that a provider might use. Others who may not know the patient might make judgments based on the label. This can lead to biases even before the provider gets to know the patient, he says.

The labels can defeat the goal of health care because the patient might not like the way he or she is treated and "might not return for follow-up care, and that produces a gap in the care."

Stereotypes, he says, can help people make sense of the world.

"But when we apply (stereotypes) to people on the basis of race or gender, we make huge mistakes."

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Part nineteen: How low can you go? Missouri falls to 39th in health rankings

At a time of much talk about health disparities and programs to improve public health, Missouri stands out for what it isn't doing. The state dropped another notch in health rankings this year while some other states improved their showings, according to a report by United Health Foundation, the American Public Health Association and Partnership for Prevention.

The study says Missouri now ranks 39th, down from 38th last year, on a number of state-by-state health-related issues. These include health behaviors, public and health policies, and community and environmental conditions.

"The point we take from the survey is that many of these health conditions are preventable through our own lifestyle choices" says Steve Walli, chief executive officer for UnitedHealthcare-Missouri and Central Southern Illinois.

"A lot of things contributes to why we are not the healthiest state. We have high rates of smoking, and obesity has increased in five years from 24.9 percent to 30.5 percent of the population. We also have relatively low rates of public-health funding."

In the survey, Vermont topped the list of healthiest states, followed by Massachusetts, New Hampshire, Connecticut and Hawaii. Several states improved by at least five ranks. Georgia improved the most, to 36th from 43rd; Idaho rose to 9th from 14th, while Nebraska jumped to 11th from 16th. Mississippi remained at the very bottom, followed by Louisiana, Arkansas, Nevada and Oklahoma.

getting beyond labels

Missouri's level of public-health funding was cited earlier this year in a Trust for America's Health report. It said the state spent only $9.26 a person on public health, compared to a national average of $28.92. The funding ranges from a low of $3.55 a person in Nevada, followed by Missouri's $9.26 rate, to a high of $169.92 a person in Hawaii. An example of what the low spending can mean: Missouri's low child immunization rate of only 56 percent, compared to a national rate of nearly 71 percent. Four years ago, the rate was nearly 81 percent.

"This should be a wakeup call," Jeff Levi, executive director for Trust for America's Health, said of Missouri's ranking. "Things aren't going to get better in these fiscal times of even more budget cuts. But we absolutely need to make investments in public health even in difficult times. You shouldn't cut back on health."

The Missouri Public Health Association sent that same message to Gov. Jay Nixon last month, appealing to him to find ways to invest more in public health. The letter from the association's president, Patrick Morgester, stressed that "no single administration, legislative body or state health department director is to blame since the decline has been ongoing over 10-15 years."

The group also made the frequently mentioned suggestion that Missouri raise its tobacco tax and make sure the millions of dollars from the tobacco settlement lawsuit be used for programs to stop smoking.

Overall, Missouri is spending 16.3 percent less for public health this year than in 2000, the association says. It adds that "until such time as a public-health system is allowed to grow and prosper in this state, Missourians are doomed to reap the miserable outcomes and unnecessary human and economic costs that they face."

In a response to the group's letter, Nixon's office said the governor was "working toward making state government more efficient and ensuring the highest possible quality of life for all Missourians."

invest in prevention

Bernard Malone, an association board member, says, "The problem is that Missouri does not invest in prevention, which is the major focus of public health. The state's priorities are unbalanced. It would rather pay for medical care than for preventive services."

In its comprehensive report, developed by research coordinator Maggie Callon, Vision for Children at Risk calls attention to Missouri's relatively low investment in promoting children's well-being.

Vision also notes that one of the only bright spots in human development programs in Missouri is coming, not from the state, but from local jurisdictions through the creation of Community Children's Services Funds.

In 2004, St. Louis set up its fund, as did St. Charles, Jefferson and Lincoln counties. In 2008, St. Louis County set up one through a 1/4-cent tax measure. These are turning out to be a lifeline. Vision notes that the funds have generated about $60 million a year to meet the needs of children and their families.

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