As of May 30, only three people in the United States had tested positive after being exposed to a wave of bird flu spreading among cows. Those people, dairy farm workers in Texas and Michigan, experienced eye irritation. One of them also had a cough and sore throat.

Scientists warn the virus could mutate to spread from person to person like the seasonal flu, which could spark a pandemic. By keeping tabs on farmworkers, researchers could track infections, learn how dangerous they are, and be alerted if the virus becomes more infectious.

But people generally get tested when they seek treatment for illnesses. Farmworkers rarely do that, because many lack health insurance and paid sick leave, said Elizabeth Strater, director of strategic campaigns for the national group United Farm Workers. They are unlikely to go to a doctor unless they become very ill.

Strater said about 150,000 people work in U.S. dairies. She said many worker advocates believe the virus has spread to more people than tests are showing. “The method being used to surveil at-risk workers has been very passive,” she said.

Federal officials told reporters May 22 that just 40 people connected to U.S. dairy farms had been tested for the virus, although others are being “actively monitored” for symptoms.

Federal authorities they would pay farmworkers $75 each to be tested for the virus, as part of a new program that also offers incentives for farm owners to allow testing of their dairy herds.

Officials of the federal Centers for Disease Control and Prevention said they recognize the importance of gaining cooperation and trust from front-line dairy employees.

CDC spokesperson Rosa Norman said in an email that the incentive payment compensates workers for their time contributing to the monitoring of how many people are infected, how sick they become, and whether humans are spreading the virus to each other.

She noted the CDC believes the virus currently poses a .

But Strater is skeptical of the incentive for farmworkers to be checked for the virus. If a worker tests positive, they’d likely be instructed to go to a clinic then stay home from work. She said they couldn’t afford to do either.

“That starts to sound like a really bad deal for 75 bucks, because at the end of the week, they’re supposed to feed their families,” she said.

Katherine Wells, director of public health in Lubbock, Texas, said that in her state, health officials would provide short-term medical care, such as giving farmworkers the flu treatment Tamiflu. Those arrangements wouldn’t necessarily cover hospitalization if it were needed, she said.

She said the workers’ bigger concern appears to be that they would have to stay home from work or might even lose their jobs if they tested positive.

Many farmworkers , and they often labor in grueling conditions for little pay.

They may fear attention to cases among them will inflame anti-immigrant fervor, said Monica Schoch-Spana, a medical anthropologist at the Johns Hopkins Center for Health Security.

Societies have a long marginalized communities for the spread of contagious diseases. Latino immigrants were verbally attacked during the H1N1 “swine flu” pandemic in 2009, for example, and some media personalities used the outbreak to push for a crackdown on immigration.

Bethany Boggess Alcauter, director of research and public health programs at the National Center for Farmworker Health, said many workers on dairy farms have been told very little about this new disease spreading in the cows they handle. “Education needs to be a part of testing efforts, with time for workers to ask questions,” she said.

These conversations should be conducted in the farmworkers’ language, with people they are likely to trust, she said.

Georges Benjamin, executive director of the American Public Health Association, said public health officials must make clear that workers’ immigration status will not be reported as part of the investigation into the new flu virus. “We’re not going to be the police,” he said.

Dawn O’Connell, an administrator at the Department of Health and Human Services, said in a press conference May 22 that nearly 5 million doses of a vaccine against H5N1, the bird flu virus circulating in cattle, are being prepared, but that officials have not decided whether the shots will be offered to farmworkers when they’re ready later this year.

The CDC asked states in early May to share personal protective equipment with farm owners, to help them shield workers from the bird flu virus. State health departments in California, Texas, and Wisconsin, which have large dairy industries, all said they have offered to distribute such equipment.

Chris Van Deusen, a Texas health department spokesperson, said four dairy farms had requested protective equipment from the state stockpile. He said other farms may already have had what they needed. Spokespeople for the California and Wisconsin health departments said they did not immediately receive requests from farm owners for the extra equipment.

Strater, the United Farm Workers official, said protective equipment offerings need to be practical.

Most dairy workers already wear waterproof aprons, boots, and gloves, she said. It wouldn’t be realistic to expect them to also wear N95 face masks in the wet, hot conditions of a milking operation, she said. Plastic face shields seem like a better option for that environment, especially to prevent milk from spraying into workers’ eyes, where it could cause infection, she said.

Other types of agricultural workers, including those who work with chickens, also face potential infection. But scientists say the version of the virus spreading in cows could be particularly dangerous, because it has adapted to live in mammals.

Strater said she’s most worried about dairy workers, who spend 10 to 12 hours a day in enclosed spaces with cows.

“Their faces are approximately 5 inches away from the milk and the udders all day long,” she said. “The intimacy of it, where their face is so very close to the infectious material, is different.”

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But that’s not the case in the American South. And especially not for Black women.

In South Carolina, Black women were more than four times as likely to die of a pregnancy-related cause in 2020 than White women. And discrimination was a factor in more than a third of the state’s 18 pregnancy-related deaths of women of all races, by the state’s Department of Health and Environmental Control.

Discrimination was the most common circumstance associated with South Carolina maternal deaths from 2018 to 2020, the report found, topping obesity, substance use disorders and mental health conditions.

It’s a problem across the South. Arkansas had the highest maternal mortality rate in the United States from 2018 to 2021, according to 鈥� 43.5 deaths per 100,000 live births, about four times the rate in California. Mississippi had the second-highest rate: 43 deaths per 100,000 live births. The top eight states are all below the Mason-Dixon Line.

South Carolina’s overall pregnancy-related mortality rate dropped by 16 percent from 2019 to 2020, but improvement was observed only among White patients. The pregnancy-related mortality rate among Black women increased year over year, and the gap in pregnancy-related deaths between Black and White people widened, according to the state’s report.

A spokesperson for South Carolina Gov. Henry McMaster, a Republican, did not respond to questions about the report, and no one from the state health department was made available to be interviewed about its findings. Via email, agency spokesperson Casey White highlighted that the report recommends hospitals and health providers across the state mandate cultural competency training for employees to address discrimination.

“When you say racism, people think of the worst of the worst 鈥� a Klansman or something of that level,” said Lesley Rathbun, a certified nurse-midwife who sits on the state’s Maternal Morbidity and Mortality Review Committee, which produced the report. But racism in health care, she said, is often so pervasive that many providers don’t even recognize it.

For example, some nurses and doctors still believe Black patients have a different tolerance for pain than White patients.

“That’s the kind of thing that’s been entrenched in health care for a very long time,” she said. “We have a very long history of racism.”

The review committee first convened in 2016. Rathbun said the group meets quarterly to review pregnancy-related deaths.

Members consider evidence including medical records, autopsy reports and interviews that health department nurses conduct with surviving family members to determine if a death is pregnancy-related.

The group examined 79 deaths in 2020 and determined that 18 were pregnancy-related. Seventeen of those deaths, the panel determined, were preventable.

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• Read Sable-Smith and Lowe’s “Three People Shot at Super Bowl Parade Grapple With Bullets Left in Their Bodies”

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蘑菇影院 Health News senior South Carolina correspondent Lauren Sausser discussed genetic diversity in research on the “America’s Heroes Group” podcast on May 11.

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The key word there is “diverse.” So far,听the program has collected听more than 560,000 DNA samples, and nearly half of participants identify as being part of a racial or ethnic minority group.

NIH researchers strategically partnered with community health centers, faith-based groups, and Black fraternities and sororities to recruit people who have been historically underrepresented in biomedical research.

“We are actually looking to overrepresent” these previously marginalized groups, explained听Martin Mendoza, director of health equity for All of Us, which will continue to enroll participants through at least 2026, when researchers intend to evaluate the next phases of the project.

Their success to date is remarkable for a few reasons.听听is typically low in diversity. And when it comes to genetics research specifically, diversity has been nearly nonexistent.

Since the completion more than 20 years ago of the听Human Genome Project, which mapped most human genes for the first time, nearly 90 percent of genomics studies have been conducted using DNA from participants of European descent,听.

Humans of all races and ethnicities are 99 percent genetically identical. But even small differences in our DNA can have a profound impact on our health.

Here’s an example: A few years ago,听听that some Black patients had been misdiagnosed with a potentially fatal heart condition called听hypertrophic cardiomyopathy听because they’d tested positive for genetic variants that were thought to be harmful. But it turns out the variants, more common among听Black Americans听than among听White Americans, are likely harmless. The diagnosis, though, is life-altering 鈥� patients with hypertrophic cardiomyopathy have traditionally been discouraged from competing in sports, for example.

Such misdiagnoses can be avoided if “even modest numbers of people from diverse populations are included in sequence databases,” NIH wrote.

Easier said than done. A genetics research project underway in听South Carolina听肠补濒濒别诲听In Our DNA SC听is struggling to recruit enough Black participants. The scientists behind the project said two years ago they aimed to collect samples reflecting the diversity of the state, where 27 percent of residents identify as Black or African American.

“We’d like to be a lot more diverse,” said听Daniel Judge, principal investigator for the study and a cardiovascular genetics specialist at the听Medical University of South Carolina.

To date, only about 12 percent of participants who provided socio-demographic data identify as Black. An additional 5 percent identify as belonging to another racial minority.

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Like other residents, she got an unwelcome surprise in October 2022 at a public forum held by the Environmental Protection Agency at the historic Monumental Baptist Church, known for its role in the civil rights movement. The EPA notified the predominantly Black community that Sterilization Services of Tennessee 鈥攚hich began operations in the brick building in the 1970s 鈥� had been emitting unacceptably high levels of ethylene oxide, a toxic gas commonly used to disinfect medical devices.

Airborne emissions of the colorless gas can increase the , including breast cancer. Sims, who is 59 and Black, said she developed breast cancer in 2019, despite having no family history of it, and she suspects ethylene oxide was a contributing factor.

“I used to be outside a lot. I was in good health. All of a sudden, I got breast cancer,” she said.

Local advocates say the emissions are part of a pattern of environmental racism. The term is often applied when areas populated primarily by racial and ethnic minorities and members of low-socioeconomic backgrounds, like southwest Memphis, are burdened with a disproportionate amount of health hazards.

The drivers of environmental racism include the promise of tax breaks for industry to locate a facility in a heavily minority community, said Malini Ranganathan, an urban geographer at American University in Washington, D.C. The cheaper cost of land also is a factor, as is the concept of NIMBY 鈥� or “not in my backyard” 鈥� in which power brokers steer possible polluters to poorer areas of cities.

A manager at Sterilization Services’ corporate office in Richmond, Virginia, declined to answer questions from 蘑菇影院 Health News. An attorney with Leitner, Williams, Dooley & Napolitan, a law firm that represents the company, also declined to comment. Sterilization Services, in a legal filing asking for an ethylene oxide-related lawsuit to be dismissed, said the use of the gas, which sterilizes about half the medical devices in the U.S., is highly regulated to ensure public safety.

Besides southwest Memphis, there are nearly two dozen locales, mostly small cities 鈥� from Athens, Texas, to Groveland, Florida, and Ardmore, Oklahoma 鈥� where the EPA said in 2022 that plants sterilizing medical devices emit the gas at unusually high levels, potentially increasing a person’s risk of developing cancer.

The pollution issue is so bad in southwest Memphis that even though Sterilization Services planned to close shop by April 30, local community leaders have been hesitant to celebrate. In a letter last year to a local Congress member, the company said it has always complied with federal, state, and local regulations. The reason for its closure, it said, was a problem with renewing the building lease.

But many residents see it as just one small win in a bigger battle over environmental safety in the neighborhood.

“It’s still a cesspool of pollution,’’ said Yolonda Spinks, of the environmental advocacy organization Memphis Community Against Pollution, about a host of hazards the community faces.

The air in this part of the city has long been considered dangerous. An spews a steady plume of white smoke. A coal plant, which is now closed, leaked components of coal ash, such as arsenic, into the ground and groundwater, according to from the Tennessee Valley Authority. The TVA is proposing to gut an existing gas plant and replace turbines in the facility with new ones.听A continual stream of heavy trucks chug along nearby highways and roads. Other transportation sources of air pollution include the Memphis International Airport and barge traffic on the nearby Mississippi River.

Lead contamination is also a concern, not just in drinking water but in the soil from now-closed lead smelters, said , a professor of environmental health at the University of Memphis. Almost all the heavy industry in Shelby County 鈥� and the associated pollutants 鈥� are located in southwest Memphis, Jia added.

Sources of pollution are often “clustered in particular communities,” said Darya Minovi, a senior analyst with the Union of Concerned Scientists, a nonprofit that advocates for environmental justice. When it comes to sterilizing facilities that emit ethylene oxide, areas inhabited largely by Black, Hispanic, low-income, and non-English-speaking people are disproportionately exposed, the group has found.

Four sites that the EPA labeled high-risk are in low-income areas of Puerto Rico. Seven sterilizer plants operate in that U.S. territory.

The EPA, responding to public concerns and to deepened scientific understanding of the hazards of ethylene oxide, recently released rules that the agency said would greatly reduce emissions of the toxic gas from sterilizing facilities.

KeShaun Pearson, who was born and raised in south Memphis and has been active in fighting environmental threats, said he is frustrated that companies with dangerous emissions are allowed to create “toxic soup” in minority communities.

In the area where the sterilization plant is located, 87% of the residents are people of color, and, according to the Southern Environmental Law Center, life expectancy there is about 10 years lower than the average for the county and state. The population within 5 miles of the sterilizer plant is mostly low-income, according to the Union of Concerned Scientists.

Pearson was part of Memphis Community Against the Pipeline, a group formed in 2020 to stop a crude oil pipeline that would have run through Boxtown, a neighborhood established by emancipated slaves and freedmen after the signing of the Emancipation Proclamation of 1863.

That campaign, which received public support from former Vice President Al Gore and actress-activist Jane Fonda, succeeded. After the ethylene oxide danger surfaced in 2022, the group changed the last word of its name from “pipeline” to “pollution.”

Besides breast and lymphoid cancers, animal studies have linked inhaling the gas to tumors of the brain, lungs, connective tissue, uterus, and mammary glands.

Last year, with the help of the Southern Environmental Law Center, the south Memphis community group urged the Shelby County Health Department to declare the ethylene oxide situation a public health emergency and shut down the sterilizing plant. But the health department said the company had complied with its existing air permit and with the EPA’s rules and regulations.

A health department spokesperson, Joan Carr, said Shelby County enforces EPA regulations to ensure that companies comply with the federal Clean Air Act and that the agency has five air monitoring stations around the county to detect levels of other pollutants.

When the county and the Tennessee Department of Health did a cancer cluster study in 2023, the agencies found no evidence of the clustering of high rates of leukemia, non-Hodgkin lymphoma, or breast or stomach cancer near the facility. There were “hot and cold spots” of breast cancer found, but the study said it could not conclude that the clusters were linked to the facility.

Scientists have criticized the study’s methodology, saying it did not follow the Centers for Disease Control and Prevention’s recommendations for designing a cancer cluster investigation.

Meanwhile, several people have sued the sterilizing company, claiming their health has been affected by the ethylene oxide emissions. In a lawsuit seeking class-action status, Reginaé Kendrick, 21, said she was diagnosed with a brain tumor at age 6. Chemotherapy and radiation have stunted her growth, destroyed her hair follicles, and prevented her from going through puberty, said her mother, Robbie Kendrick.

In response to proposed stricter EPA regulations, meanwhile, the Tennessee attorney general helped lead 19 other state AGs in urging the agency to “forgo or defer regulating the use of EtO by commercial sterilizers.”

Sims said she’s glad her neighborhood will have one less thing to worry about once Sterilization Services departs. But her feelings about the closure remain tempered.

“Hope they don’t go to another residential area,” she said.

[Clarification: This article was updated at 3:15 p.m. ET on May 1, 2024, to specify which substances leaked into the ground and groundwater and what changes will occur related to the Tennessee Valley Authority’s activities in Shelby County, Tennessee.]

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Since then, mandatory reporting laws have expanded nationally to include more types of maltreatment 鈥� including neglect, which now accounts for most reports 鈥� and have increased the number of professions required to report. In some states, are required to report what they suspect may be abuse or neglect.

But now there are efforts in Colorado and other states to roll back these laws, saying the result has been too many unfounded reports, and that they disproportionately harm families that are poor, Black, or Indigenous, or have members with disabilities.

“There’s a long, depressing history based on the approach that our primary response to a struggling family is reporting,” said Mical Raz, a physician and historian at the University of Rochester in New York. “There’s now a wealth of evidence that demonstrates that more reporting is not associated with better outcomes for children.”

Stephanie Villafuerte, Colorado’s child protection ombudsman, oversees a task force to reexamine the state’s mandatory reporting laws. She said the group is seeking to balance a need to report legitimate cases of abuse and neglect with a desire to weed out inappropriate reports.

“This is designed to help individuals who are disproportionately impacted,” Villafuerte said. “I’m hoping it’s the combination of these efforts that could make a difference.”

Some critics worry that changes to the law could result in missed cases of abuse. Medical and child care workers on the task force have expressed concern about legal liability. While it’s rare for people to be criminally charged for failure to report, they can also face civil liability or professional repercussions, including threats to their licenses.

Being reported to child protective services is becoming increasingly common. More than 1 in 3 children in the United States will be the subject of a child abuse and neglect investigation by the time they turn 18, according to the most frequently cited estimate, a funded by the Department of Health and Human Services’ Children’s Bureau.

Black and Native American families, poor families, and or with disabilities experience even more oversight. Research has found that, among these groups, parents are more likely to lose parental rights and children are more likely to wind up in foster care.

In an of investigations, no abuse or neglect is substantiated. Nonetheless, researchers who study describe them as terrifying and isolating.

In Colorado, the number of child abuse and neglect reports has increased 42% in the past decade and reached a record 117,762 last year, according to . Roughly 100,000 other calls to the hotline weren’t counted as reports because they were requests for information or were about matters like child support or adult protection, said officials from the Colorado Department of Human Services.

The increase in reports can be traced to a policy of encouraging a broad array of professionals 鈥� including school and medical staff, therapists, coaches, clergy members, firefighters, veterinarians, dentists, and social workers 鈥� to call a hotline whenever they have a concern.

These calls don’t reflect a surge in mistreatment. More than two-thirds of the reports received by agencies in Colorado don’t meet the threshold for investigation. Of the children whose cases are assessed, 21% are found to have experienced abuse or neglect. The actual has not risen over the past decade.

While studies do not demonstrate that mandatory reporting laws keep children safe, the Colorado task force , there is evidence of harm. “Mandatory reporting disproportionately impacts families of color” 鈥� initiating contact between child protection services and families who routinely do not present concerns of abuse or neglect, the task force said.

The task force said it is analyzing whether better screening might mitigate “the disproportionate impact of mandatory reporting on under-resourced communities, communities of color and persons with disabilities.”

The task force pointed out that the only way to report concerns about a child is with a formal report to a hotline. Yet many of those calls are not to report abuse at all but rather attempts to connect children and families with resources like food or housing assistance.

Hotline callers may mean to help, but the families who are the subjects of mistaken reports of abuse and neglect rarely see it that way.

That includes Meighen Lovelace, a rural Colorado resident who asked 蘑菇影院 Health News not to disclose their hometown for fear of attracting unwanted attention from local officials. For Lovelace’s daughter, who is neurodivergent and has physical disabilities, the reports started when she entered preschool at age 4 in 2015. The teachers and medical providers making the reports frequently suggested that the county human services agency could assist Lovelace’s family. But the investigations that followed were invasive and traumatic.

“Our biggest looming fear is, 鈥楢re you going to take our children away?’” said Lovelace, who is an advocate for the Colorado Cross-Disability Coalition, an organization that lobbies for the civil rights of people with disabilities. “We’re afraid to ask for help. It’s keeping us from entering services because of the fear of child welfare.”

State and county human services officials said they could not comment on specific cases.

The Colorado task force plans to suggest clarifying the definitions of abuse and neglect under the state’s mandatory reporting statute. Mandatory reporters should not “make a report solely due to a family/child’s race, class or gender,” nor because of inadequate housing, furnishings, income or clothing. Also, there should not be a report based solely on the “disability status of the minor, parent or guardian,” according to the group’s draft recommendation.

The task force plans to recommend additional training for mandatory reporters, help for professionals who are deciding whether to make a call, and an alternative phone number, or “warmline,” for cases in which callers believe a family needs material assistance, rather than surveillance.

Critics say such changes could leave more children vulnerable to unreported abuse.

“I’m concerned about adding systems such as the warmline, that kids who are in real danger are going to slip through the cracks and not be helped,” said Hollynd Hoskins, an attorney who represents victims of child abuse. Hoskins has sued professionals who fail to report their suspicions.

The Colorado task force includes health and education officials, prosecutors, victim advocates, county child welfare representatives and attorneys, as well as five people who have experience in the child welfare system. It intends to finalize its recommendations by early next year in the hope that state legislators will consider policy changes in 2025. Implementation of any new laws could take several years.

Colorado is one of several states 鈥� including and 鈥� that have recently considered changes to restrain, rather than expand, reporting of abuse. In New York City, teachers are being trained to before making a report, while New York state to help connect families with resources like housing and child care. In California, a state aimed at shifting “mandated reporting to community supporting” is planning recommendations .

Among those advocating for change are people with experience in the child welfare system. They include , who leads the Denver-based MJCF Coalition, which advocates for the abolition of mandatory reporting along with the rest of the child welfare system, citing its damage to Black, Native American, and Latino communities.

“Mandatory reporting is another form of keeping us policed and surveillanced by whiteness,” said Jihad, who as a child was taken from the care of a loving parent and placed temporarily into the foster system. Reform isn’t enough, she said. “We know what we need, and it’s usually funding and resources.”

Some of these resources 鈥� like affordable housing and child care 鈥� don’t exist at a level sufficient for all the Colorado families that need them, Jihad said.

Other services are out there, but it’s a matter of finding them. Lovelace said the reports ebbed after the family got the help it needed, in the form of a Medicaid waiver that paid for specialized care for their daughter’s disabilities. Their daughter is now in seventh grade and doing well.

None of the caseworkers who visited the family ever mentioned the waiver, Lovelace said. “I really think they didn’t know about it.”

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“It’s a walking billboard,” said Moultrie, a health care advocate who serves on the community advisory board for In Our DNA SC, a study underway at the university that aims to enroll 100,000 South Carolinians 鈥� including a representative percentage of Black people 鈥� in genetics research. The goal is to better understand how genes affect health risks such as cancer and heart disease.

Moultrie, who is Black and has participated in the research project himself, used the opportunity at the dental clinic to encourage the women to sign up and contribute their DNA. He keeps brochures about the study in his car and at the barbershop he visits weekly for this reason. It’s one way he wants to help solve a problem that has plagued the field of genetics research for decades: The data is based mostly on DNA from white people.

Project leaders in Charleston told 蘑菇影院 Health News in 2022 that they hoped to enroll participants who reflect the demographic diversity of South Carolina, where just under 27% of residents identify as Black or African American. To date, though, they’ve failed to hit that mark. Only about 12% of the project’s participants who provided sociodemographic data identify as Black, while an additional 5% have identified as belonging to another racial minority group.

“We’d like to be a lot more diverse,” acknowledged Daniel Judge, principal investigator for the study and a cardiovascular genetics specialist at the Medical University of South Carolina.

Lack of diversity in genetics research has real health care implications. Since the completion more than 20 years ago of the Human Genome Project, which mapped most human genes for the first time, close to 90% of genomics studies have been conducted using DNA from participants of European descent, . And while human beings of all races and ancestries are more than 99% genetically identical, even small differences in genes can spell big differences in health outcomes.

“Precision medicine” is a term used to describe how genetics can improve the way diseases are diagnosed and treated by considering a person’s DNA, environment, and lifestyle. But if this emerging field of health care is based on research involving mostly white people, “it could lead to mistakes, unknowingly,” said Misa Graff, an associate professor in epidemiology at the University of North Carolina and a genetics researcher.

In fact, that’s already happening. In 2016, for example, that some Black patients had been misdiagnosed with a potentially fatal heart condition because they’d tested positive for a genetic variant thought to be harmful. That variant is much more common among Black Americans than white Americans, the research found, and is considered likely harmless among Black people. Misclassifications can be avoided if “even modest numbers of people from diverse populations are included in sequence databases,” the authors wrote.

The genetics research project in Charleston requires participants to complete an online consent form and submit a saliva sample, either in person at a designated lab or collection event or by mail. They are not paid to participate, but they do receive a report outlining their DNA results. Those who test positive for a genetic marker linked to cancer or high cholesterol are offered a virtual appointment with a genetics counselor free of charge.

Some research projects require more time from their volunteers, which can skew the pool of participants, Graff said, because not everyone has the luxury of free time. “We need to be even more creative in how we obtain people to help contribute to studies,” she said.

Moultrie said he recently asked project leaders to reach out to African American media outlets throughout the Palmetto State to explain how the genetics research project works and to encourage Black people to participate. He also suggested that when researchers talk to Black community leaders, such as church pastors, they ought to persuade those leaders to enroll in the study instead of simply passing the message along to their congregations.

“We have new ideas. We have ways we can do this,” Moultrie said. “We’ll get there.”

Other ongoing efforts are already improving diversity in genetics research. At the National Institutes of Health, a program called “All of Us” aims to analyze the DNA of more than 1 million people across the country to build a diverse health database. So far, that program has enrolled more than 790,000 participants. Of these, more than 560,000 have provided DNA samples and about 45% identify as being part of a racial or ethnic minority group.

“Diversity is so important,” said Karriem Watson, chief engagement officer for the . “When you think about groups that carry the greatest burden of disease, we know that those groups are often from minoritized populations.”

Diverse participation in All of Us hasn’t come about by accident. NIH researchers strategically partnered with community health centers, faith-based groups, and Black fraternities and sororities to recruit people who have been historically underrepresented in biomedical research.

In South Carolina, for example, the NIH works with Cooperative Health, a network of federally qualified health centers near the state capital that serve many patients who are uninsured and Black, to recruit patients for All of Us. Eric Schlueter, chief medical officer of Cooperative Health, said the partnership works because their patients trust them.

“We have a strong history of being integrated into the community. Many of our employees grew up and still live in the same communities that we serve,” Schlueter said. “That is what is part of our secret sauce.”

So far, Cooperative Health has enrolled almost 3,000 people in the research program, about 70% of whom are Black.

“Our patients are just like other patients,” Schlueter said. “They want to be able to provide an opportunity for their children and their children’s children to have better health, and they realize this is an opportunity to do that.”

Theoretically, researchers at the NIH and the Medical University of South Carolina may be trying to recruit some of the same people for their separate genetics studies, although nothing would prevent a patient from participating in both efforts.

The researchers in Charleston acknowledge they still have work to do. To date, In Our DNA SC has recruited about half of the 100,000 people it hopes for, and of those, about three-quarters have submitted DNA samples.

Caitlin Allen, a program investigator and a public health researcher at the medical university, acknowledged that some of the program’s tactics haven’t succeeded in recruiting many Black participants.

For example, some patients scheduled to see providers at the Medical University of South Carolina receive an electronic message through their patient portal before an appointment, which includes information about participating in the research project. But studies show that racial and ethnic minorities are less likely to engage with their electronic health records than white patients, Allen said.

“We see low uptake” with that strategy, she said, because many of the people researchers are trying to engage likely aren’t receiving the message.

The study involves four research coordinators trained to take DNA samples, but there’s a limit to how many people they can talk to face-to-face. “We’re not necessarily able to go into every single room,” Allen said.

That said, in-person community events seem to work well for enrolling diverse participants. In March, In Our DNA SC research coordinators collected more than 30 DNA samples at a bicentennial event in Orangeburg, South Carolina, where more than 60% of residents identify as Black. Between the first and second year of the research project, Allen said, In Our DNA SC doubled the number of these community events that research coordinators attended.

“I would love to see it ramp up even more,” she said.

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Many of its patients are aging Chinese speakers with limited incomes who are reliant on Medicare and Medi-Cal, which pay less than commercial insurance and often don’t fully cover provider costs. And due to an arcane federal rule, Chinese Hospital receives a lower rate of reimbursement than many other hospitals that treat a large number of low-income patients. Add the in this post-pandemic world, and it’s not hard to see why the hospital lost $20 million over the past two years and tapped a nearly $10.4 million loan from the state’s distressed hospital loan fund.

Yet the 88-bed hospital has strong ties to the University of California-San Francisco and the city’s public health department. And it gets support from businesses, charities, and the surrounding community. For Jian Zhang, 58, the hospital’s CEO since 2017, fundraising is like breathing.

“I feel like it’s a full-time job for me,” said Zhang, who arrived in San Francisco from Guangzhou, China, as an international student in 1990, earned a nursing doctorate from the University of San Francisco, and has remained in the Bay Area.

Revenue from fundraising and other services have provided a big boost, helping the hospital significantly offset what it lost on patient care in 2022, according to the hospital and state data. By contrast, Madera Community Hospital and Beverly Hospital were far less able to do so. Those hospitals, which also serve low-income populations with many patients on government health care programs, filed for bankruptcy last year.

Chinese Hospital has its roots in a medicinal dispensary, founded in 1899 to provide health care for Chinese immigrants who were effectively excluded from mainstream medical facilities. The hospital itself opened in 1925, and a second building was added next door in 1979. In 2016, a new building replaced the original hospital.

Today, Chinese Hospital includes those two buildings plus five outpatient clinics offering Eastern and Western medicine, spread out across San Francisco and neighboring San Mateo County. Through partnerships, Chinese Hospital has been able to offer specialty services to its patients, including eye surgery, palliative care, and a stroke center. And $10 million in grants it received from the state last year will help build a subacute unit, which is for fragile patients who still need nursing and monitoring following a hospital stay.

In an interview with 蘑菇影院 Health News senior correspondent Bernard J. Wolfson, Zhang discussed the challenges facing small independent hospitals, including Chinese Hospital, and offered her vision for its future. The following Q&A has been edited for length and clarity:

Q: What are some of the main challenges your hospital faces?

We are facing all the challenges other hospitals are facing, especially the covid pandemic and its associated negative impact 鈥� the physician shortage and workforce shortage, the labor cost increases. But as a small community hospital, we don’t have a lot of reserve money. It’s hard to make ends meet.

That is a huge challenge because of the low reimbursement rate. We serve more than 80% Medicare and Medi-Cal patients.

Q: What are some specific challenges of serving a largely Chinese population?

In this market, with the workforce shortage, and especially after the pandemic, it’s even harder to recruit bilingual physicians, and other bilingual staff.

And culturally, Chinese patients, when they are sick, need to drink soup for healing or eat certain other foods for healing. You can’t be providing sandwiches and salads. They won’t eat that. So our kitchen has to provide Chinese food, has to boil soup, and then we have to cook different food for our patients who are non-Chinese.

Q: Are you concerned about the state’s budget shortfall?

Absolutely. We all were expecting that Medi-Cal would increase rates. We have been pushing that for many years. But if it’s not going to happen, a lot of our programs we probably won’t be able to do. I am very concerned about it.

Q: Chinese Hospital has its own health plan, and you said 40% to 50% of your patients are members of it. How has that helped?

It’s like Kaiser Permanente. You have your own members, and you manage them. You want your patients to be in outpatient. So you take care of them, keep them healthy, so they don’t need to come to the hospital for acute care. That’s how you save money.

Q: And I imagine that getting fixed monthly payments 鈥� capitation payments 鈥� for a large proportion of your patients also helps?

Definitely, capitation payments help. Especially during the pandemic. Think about it. If you didn’t have capitation payments, when procedures were canceled, you didn’t have income.

Q: What else has helped you weather the storm?

We have partnerships with San Francisco’s Department of Public Health and UCSF. During the pandemic, we took overflow patients from the city, so we didn’t have to lay off a lot of people. We signed a contract with the city to open up the second floor of our hospital to take overflow patients from Zuckerberg San Francisco General hospital.

Q: You also have strong fundraising activity.

We do have strong community support. The hospital is not just a hospital to me. It’s really part of our history. In the past, it was the only place [Chinese people] could go. Wherever I went, to a conference, for example, somebody would raise their hand and say, “Oh, I was born at Chinese Hospital” or “My grandfather was born at Chinese Hospital.” It is really, really deeply rooted in the community.

Q: What’s your vision for the future of the hospital?

Chinese Hospital is very important to the community, and I want to see it survive and thrive. But it definitely needs support from the government and from the community. Moving forward, we will continue to build on collaborations and partnerships.

This article was produced by 蘑菇影院 Health News, which publishes , an editorially independent service of the .听

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Goodlow, a member of the Lower Brule Sioux Tribe, said she’s lost six friends and acquaintances to suicide, two to car crashes, and one to appendicitis. Four of her relatives died in their 30s or 40s, from causes such as liver failure and covid-19, she said. And she recently lost a 1-year-old nephew.

“Most Native American kids and young people lose their friends at a young age,” said Goodlow, who is considering becoming a mental health therapist to help her community. “So, I’d say we’re basically used to it, but it hurts worse every time we lose someone.”

Native Americans tend to die much earlier than white Americans. Their median age at death was 14 years younger, according to an analysis of 2018-21 data from the Centers for Disease Control and Prevention

The disparity is even greater in Goodlow’s home state. Indigenous South Dakotans who died between 2017 and 2021 had a median age of 58 鈥� 22 years younger than white South Dakotans,

Donald Warne, a physician who is co-director of the Johns Hopkins Center for Indigenous Health and a member of the Oglala Sioux Tribe, can rattle off the most common medical conditions and accidents killing Native Americans.

But what’s ultimately behind this low life expectancy, agree Warne and many other experts on Indigenous health, are social and economic forces. They argue that in addition to bolstering medical care and fully funding the Indian Health Service 鈥� which provides health care to Native Americans 鈥� there needs to be a greater investment in case management, parenting classes, and home visits.

“It’s almost blasphemy for a physician to say,” but “the answer to addressing these things is not hiring more doctors and nurses,” Warne said. “The answer is having more community-based preventions.”

The Indian Health Service funds of these programs, including initiatives, and efforts to increase access to fresh produce and traditional foods.

and state Medicaid programs, including South Dakota’s, are such services. But insurers don’t pay for all the services and aren’t reaching everyone who qualifies, according to Warne and the .

Warne pointed to , a program developed by the Johns Hopkins center to improve health outcomes for Indigenous mothers and children.

Chelsea Randall, the director of maternal and child health at the Great Plains Tribal Leaders’ Health Board, said community health workers educate Native pregnant women and connect them with resources during home visits.

“We can be with them throughout their pregnancy and be supportive and be the advocate for them,” said Randall, whose organization runs Family Spirit programs across seven reservations in the Dakotas, and in Rapid City, South Dakota.

The community health workers help families until children turn 3, teaching parenting skills, family planning, drug abuse prevention, and stress management. They can also integrate the tribe’s culture by, for example, using their language or birthing traditions.

The health board funds Family Spirit through a grant from the federal Health Resources and Services Administration, Randall said. Community health workers, she said, use some of that money to provide child car seats and to teach parents how to properly install them to counter high rates of fatal crashes.

Other causes of early Native American deaths include homicide, drug overdoses, and chronic diseases, such as diabetes, Warne said. Native Americans also suffer a disproportionate number of infant and maternal deaths.

The crisis is evident in the obituaries from the Sioux Funeral Home, which mostly serves Lakota people from the Pine Ridge Reservation and surrounding area. The funeral home’s posts obituaries for older adults, but also for many infants, toddlers, teenagers, young adults, and middle-aged residents.

Misty Merrival, who works at the funeral home, blames poor living conditions. Some community members struggle to find healthy food or afford heat in the winter, she said. They may live in homes with broken windows or that are crowded with extended family members. Some neighborhoods are strewn with trash, including intravenous needles and broken bottles.

Seeing all these premature deaths has inspired Merrival to keep herself and her teenage daughter healthy by abstaining from drugs and driving safely. They also talk every day about how they’re feeling, as a suicide-prevention strategy.

“We’ve made a promise to each other that we wouldn’t leave each other like that,” Merrival said.

live in small towns or on poor, rural reservations. But rurality alone doesn’t explain the gap in life expectancy. For example, white people in rural Montana live 17 years longer, on average, than Native Americans in the state, reported by Lee Enterprises newspapers.

Many Indigenous people also face racism or personal trauma from child or sexual abuse and exposure to drugs or violence, Warne said. Some also deal with generational trauma from that broke up families and tried to suppress Native American culture.

Even when programs are available, they’re not always accessible.

Families without听strong internet connections can’t easily make video appointments. Some lack cars or gas money to travel to clinics, and public transportation options are limited.

Randall, the health board official, is pregnant and facing her own transportation struggles.

It’s a three-hour round trip between her home in the town of Pine Ridge and her prenatal appointments in Rapid City. Randall has had to cancel several appointments when family members couldn’t lend their cars.

Goodlow, the 20-year-old who has lost several loved ones, lives with seven other people in her mother’s two-bedroom house along a gravel road. Their tiny community on the Pine Ridge Reservation has homes and ranches but no stores.

Goodlow attended several suicide-prevention presentations in high school. But the programs haven’t stopped the deaths. One friend recently killed herself after enduring the losses of her son, mother, best friend, and a niece and nephew.

A month later, another friend died from a burst appendix at age 17, Goodlow said. The next day, Goodlow woke up to find one of her grandmother’s parakeets had died. That afternoon, she watched one of her dogs die after having seizures.

“I thought it was like some sign,” Goodlow said. “I started crying and then I started thinking, 鈥榃hy is this happening to me?’”

Warne said the overall conditions on some reservations can create despair. But those same reservations, including Pine Ridge, also contain flourishing art scenes and language and cultural revitalization programs. And

Warne said federal, state, and tribal governments need to work together to improve life expectancy. He encourages tribes to negotiate contracts allowing them to manage their own health care facilities with federal dollars because that can open funding streams not available to the Indian Health Service.

Katrina Fuller is the health director at Si膵a艐摹u Co, a nonprofit group on the Rosebud Reservation in South Dakota. Fuller, a member of the Rosebud Sioux Tribe, said the organization works toward “wicozani,” or the good way of life, which encompasses the physical, emotional, cultural, and financial health of the community.

Si膵a艐摹u Co programs include bison restoration, youth development, a Lakota language immersion school, financial education, and food sovereignty initiatives.

“Some people out here that are struggling, they have dreams, too. They just need the resources, the training, even the moral support,” Fuller said. “I had one person in our health coaching class tell me they just really needed someone to believe in them, that they could do it.”

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“We’re seeing more oral disease than the general population. There is a bigger need,” Braun said of the patients she treats at Bernard F. Gipson Eastside Family Health Center, which is part of Denver Health, the largest safety-net hospital in Colorado, serving low-income, uninsured, and underinsured residents.

Braun is part of a trend across the United States to integrate oral health into medical checkups for children, pregnant women, and others who cannot afford or do not have easy access to dentists. With federal and private funding, these programs have expanded in the past 10 years, but they face socioeconomic barriers, workforce shortages, and the challenge of dealing with the needs of new immigrants.

With a five-year, $6 million federal grant, Braun and her colleagues have helped train 250 primary care providers in oral health in Colorado, Montana, Wyoming, and Arizona. Similar projects are wrapping up in Illinois, Michigan, Virginia, and New York, funded by the federal Health Resources and Services Administration’s Maternal and Child Health Bureau. Beyond assessment, education, and preventive care, primary care providers refer patients to on- or off-site dentists, or work with embedded dental hygienists as part of their practice.

“Federally qualified health centers have a long history of co-locating dental services within their systems,” Braun said. “We’re taking that next step where care is not just co-located, meaning, say, we’re upstairs and dental is downstairs, but we’re integrated so that it becomes part of the same visit for the patient.”

Having doctors, nurses, and physician assistants who assess oral health, make referrals, and apply fluoride at community health centers is critical for the many children who lack access to dental care, said Tara Callaghan, director of operations for the Montana Primary Care Association, which represents 14 federally qualified health centers and five Urban Indian organizations.

“Providing these services during medical visits increases the frequency of fluoride application,” Callaghan said, and “improves parents’ knowledge of caring for their child’s teeth.” But obstacles remain.

Because of Montana’s large geographic area and small population, recruiting dental professionals is difficult, Callaghan said. Fifty of the state’s 56 counties are designated dental shortage areas and some counties don’t have a single dentist who takes Medicaid, she added. Montana ranks near the bottom for residents having access to , which can prevent cavities and strengthen teeth.

Pediatric dental specialists, in particular, are scarce in rural areas, with families sometimes driving hours to neighboring counties for care, she said.

Embedding dental hygienists with medical doctors is one way to reach patients in a single medical visit.

Valerie Cuzella, a registered dental hygienist, works closely with Braun and others at Denver Health, which serves nearly half of the city’s children and has embedded hygienists in five of its clinics that see children.

State regulations vary on which services hygienists can provide without supervision from a dentist. In Colorado, Cuzella can, among other things, independently perform X-rays and apply silver diamine fluoride, a tool to harden teeth and slow decay. She does all this in a cozy corner office.

Braun and Cuzella work so closely that they often finish each other’s sentences. Throughout the day they text each other, taking advantage of brief lulls when Cuzella can pop into an exam room to check for gum disease or demonstrate good brushing habits. Braun herself takes similar opportunities to assess oral health during her exams, and both focus on educating parents.

Medical and dental care have traditionally been siloed. “Schools are getting better at interprofessional collaboration and education, but by and large we train separately, we practice separately,” said Katy Battani, a registered dental hygienist and assistant professor at Georgetown University.

Battani is trying to bridge the divide by helping community health centers in nine states 鈥� including California, Texas, and Maryland 鈥� integrate dental care into prenatal visits for pregnant women. Pregnancy creates opportunities to improve oral health because some women gain dental coverage with Medicaid and see providers at least once a month, Battani said.

In Denver, housing instability, language barriers, lack of transportation, and the “astronomical cost” of dentistry without insurance make dental care inaccessible for many children, the migrant community, and seniors, said Sung Cho, a dentist who oversees the dental program at STRIDE Community Health Center, serving the Denver metro area.

STRIDE tries to overcome these barriers by offering interpretation services and a sliding pay scale for those without insurance. That includes people like Celinda Ochoa, 35, of Wheat Ridge, who waited at STRIDE Community Health Center while her 15-year-old son, Alexander, had his teeth cleaned. He was flagged for dental care during a past medical checkup and now he and his three siblings regularly see a dentist and hygienist at STRIDE.

One of Ochoa’s children has Medicaid dental coverage, but her three others are uninsured, and they couldn’t otherwise afford dental care, said Ochoa. STRIDE offers an exam, X-rays, and cleaning for $60 for the uninsured.

In the past year, Cho has seen an influx of migrants and refugees who have never seen a dentist before and need extensive care. Medical exams for refugees at STRIDE increased to 1,700 in 2023 from 1,300 in 2022, said Ryn Moravec, STRIDE’s director of development. She estimates the program has seen 800 to 1,000 new immigrants in 2024.

Even with growing needs, Cho said the Medicaid “unwinding” 鈥� the process underway to reexamine post-pandemic eligibility for the government program that provides health coverage for people with low incomes and disabilities 鈥� has created financial uncertainty. He said he worries about meeting the upfront costs of new staff and of replacing aging dental equipment.

At STRIDE’s Wheat Ridge clinic, two hygienists float between dental and pediatrics as part of the medical-dental integration. Yet Cho said he needs more hygienists at other locations to keep up with demand. The pandemic created bottlenecks of need that are only now being slowly cleared, particularly because few dentists take Medicaid. If they do accept it, they often limit the number of Medicaid patients they’ll take, said Moravec. Ideally, STRIDE could hire two hygienists and three dental assistants, Moravec said.

In 2022, Colorado enacted a law to alleviate workforce shortages by allowing 鈥� midlevel providers who do preventive and restorative care 鈥� to practice. But Colorado does not have any schools to train or accredit them.

Before age 3, children are scheduled to see a pediatrician for 12 well visits, a, particularly for at-risk children. As part of Braun’s program in the Rocky Mountain region, providers have applied more than 17,000 fluoride varnishes and increased the percentage of children 3 and younger who received preventive oral health care to 78% from 33% in its first 2陆 years.

Callaghan, at the Montana Primary Care Association, witnesses that on the ground at community health centers in Montana. “It’s about leveraging the fact that kids see their medical provider for a well-child visit much more often and before they see their dental provider 鈥� if they have one.”

蘑菇影院 Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at 蘑菇影院鈥攁n independent source of health policy research, polling, and journalism. Learn more about .

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