Public Health

Haegan Altizer (left) says Atlanta can make more progress in its biking infrastructure

Haegan Altizer is all about bicycling. He’s a state biking champion and works in sales at the Bicycle South store in Decatur.

Altizer, 17, sees good and bad in the bike-friendliness of metro Atlanta.

“Atlanta is not too bad, but it could be better for commuters,’’ Altizer tells GHN. “I’m from Decatur, and Decatur is good. There are a lot of bike lanes that have gotten built, but Atlanta’s progress does not even compare with Seattle or New York.”

Georgia bicycling enthusiasts generally see a mixed bag in terms of bike trails, infrastructure and safety measures, though many note improvements in several areas.

“The Atlanta biking population has exploded’’ in the past few years, says Rebecca Serna, executive director of the Atlanta Bicycle Coalition. Bicycle commuting to work has jumped by 400 percent in the area from 2000 to 2009, she says.

The League of American Bicyclists, a national cycling advocacy group, ranked Georgia 24th in the nation for bicycle friendliness in 2013. Georgia trailed two other Southeastern states, Virginia and Tennessee in the rankings.

The state, though, has four cities designated as bicycle-friendly: Decatur, Roswell, Athens and Tybee Island. Biking is increasing in Columbus and Augusta, Serna adds, though rural areas lag behind.

Bike trails are being built, expanded or green-lighted in the metro Atlanta counties of Cobb and Henry, as well as Carroll County and in Dalton in northwest Georgia, among other places.

Though some connections of bike paths are missing, metro Atlanta cyclists eventually will be able to ride traffic-free paths from downtown Atlanta to Woodstock, avoiding the area’s gridlocked roads, the AJC recently reported.

Bike sharing programs are being pushed in Atlanta and Decatur. They’re essentially self-service rental programs in which cities provide bikes for a fee. Atlanta’s program would start with 500 bikes at 50 stations. Bids are due this month, Maria Saporta recently reported.

Healthy, but also convenient

Nationwide, bicycling increased in the 1970s due to interruptions in foreign fuel supplies and the resulting rise in energy prices, but progress was stagnant during the 1980s and most of the 1990s, Serna says. Since then, “people started moving back into cities,’’ she says. Bicycling “is part of creating livable communities.’’

People start biking for many reasons, Serna says. She includes environmental concerns, convenience and saving money, as well as improving fitness.

The impact on health can be substantial. A Yale University study, which appeared in the American Journal of Preventative Medicine in December, found that people who use active forms of transportation, such as bicycling or walking, tend to have a lower body mass index and better cardiovascular health than those who don’t.

State officials are increasingly acknowledging the accelerating trend toward active transportation.

In September, the Georgia Department of Transportation adopted the “Complete Streets’’ policy, ensuring that plans for nearly all state and federally funded transportation projects will include safe and convenient accommodations for biking and walking.

And Georgia Public Health officials point to the 2011 adoption of HB 101, a law that requires motorists to maintain a three-foot buffer when following or passing a person on a bicycle.

Still, safety is a big concern for would-be bikers. There were 18 deaths of bicyclists on Georgia roads in 2012 — including a 9-year-old and a 12-year-old. That’s up from 14 the year before. Highway safety officials and bicycle safety advocates attribute the increased fatalities to the growing number of cyclists on the road, not to a decline in safety.

In a 2011 survey, four out of five Georgians say they would bicycle more frequently if their community were more bike-friendly.

Atlanta’s Piedmont Park and the city of Decatur are good for bicyclists, but some parts of the Atlanta area are not. “Places like Clairmont Road are ruthless,’’ says Mary Gray, 21, a marketing intern at IBM. “I have a friend whose elbow was clipped by a car on Clifton {Road], and another friend who got hit on Clifton.” Both roads are in DeKalb County, where biking is popular but traffic congestion is a problem.

“Lighting in Atlanta is poor, making night biking dangerous,’’ Gray adds.

The city of Atlanta, meanwhile, has pledged to double its bike lanes by 2016, and is investing more than $2 million in biking infrastructure. WABE recently reported. This includes adding lanes that will connect the Atlanta University Center to downtown and connect the BeltLine with Centennial Olympic Park.

And the potholes and speeding drivers aren’t going to deter bicyclists from wheeling around town.

Matt Dry, 20, an Emory University student, notes that biking “is cheap, and I don’t have to pay gas expenses.’’

And Gray adds: “I bicycle mostly to save time when I go places, but I also enjoy it. It’s not really because I’m trying to be eco-friendly, but that’s definitely a plus.”

GHN intern Sofia Kouninis, an Emory University student, contributed to this article.

Stanton Truitt of Monroe Area High School wears a Guardian Cap at a Rising Seniors Bowl practice. Photo courtesy of the Hanson Group

Chuck Petersen describes himself as an “old school’’ football guy.

He played and coached at the Air Force Academy, and now he coaches at Orange Lutheran High School in California.

A parent last year suggested Peterson’s team members wear a new type of soft padded covering for their helmets during practice, to cut down on the intensity of football hits.

The Guardian Cap has a Georgia connection. It’s designed by an Alpharetta company run by Georgia Tech grad Lee Hanson and his wife, Erin.

“At first I was a little skeptical,” Petersen recalls. But after a year of having the team use the helmet caps, made of thermoplastic material, the coach reports that only one player was lost to a head-related injury in practice during the whole 2012 season.

“I think eventually they’ll be used in games,’’ Petersen says.

The Hanson Group, a privately held company, has developed a range of protective products, from transparent armor for U.S. military vehicles to liner material for mining.
The Guardian Cap, which is snapped onto the regular helmet, is aimed at decreasing the force of impact on players’ heads.

“This was a passion product, to help these kids play these sports,’’ Erin Hanson says. She is quick to say that the helmet caps are not marketed as a means of concussion prevention, but as a way to reduce the impact of collisions.

Laws and lawsuits

Concussions in football and other sports have attracted much greater public attention in recent years. Just this week, Georgia Gov. Nathan Deal signed legislation that would require medical clearance before a school athlete returns to competition after a concussion.

Retired pro football players, meanwhile, have reported having serious neurological issues, and hundreds of them are suing the NFL over concussion-related health problems.

According to Bloomberg News, the litigation focuses attention on helmets made by Riddell – the league’s official helmet maker – and whether the NFL covered up the sport’s long-term damage to players’ brains.

Riddell, in a statement to Bloomberg, said, “Riddell’s primary mission has always been, and continues to be, providing the best protective football headgear to the athlete.’’

The NFL has denied the lawsuit claims, but has also tightened rules against helmet-to-helmet hits by players, as well as instituting a league-wide sideline testing protocol for concussions.

In March, the league passed a rules change banning players from delivering forceful blows with the crown of the helmet.

Protective coverings for helmets have been used before by NFL players. Mark Kelso, a former safety for the Buffalo Bills, wore a “ProCap’’ for five years. His last game was the Super Bowl in Atlanta in 1993.

Kelso, who had a history of concussions,  says the Bills training staff gave him an ultimatum in 1989: Wear a protective padded cap on his helmet, or he wouldn’t be cleared to play.

He took ribbing from fellow players, who called him “Bubblehead.’’ Even his wife laughed when she first saw the cap. Jim Kelly, the Bills quarterback at the time, “said it looked ridiculous,’’ Kelso says.

He played in an era, he says, when “it was a badge of honor’’ to “see stars’’ after a collision.

But in the years he wore it, Kelso says, he had only one concussion.

Kelso, who owns stock in ProCap and has done marketing for the Guardian Cap, says, “I’m an advocate for anything that has a resilient surface.’’ More concussions occur in practice than in games, he says.

“Helmet companies have made reasonable progress, albeit slow progress,’’ Kelso says. “They’ve moved too slowly. We need to continue to push the envelope.’’

An idea that is catching on

Lee and Erin Hanson hold helmets with Guardian Caps at their company’s Alpharetta office.

The Hanson Group has been tinkering with helmet design for the past four years. They gave away hundreds of the caps to youth football programs.

Last year sales began to take off. The couple says 8,000 players wore the caps in 2012.

The University of South Carolina tested the Guardian Caps during the Gamecocks’ spring practice this year, the Hansons say.

The caps retail for $55 each.

“We want to protect these youths,’’ Lee Hanson says. “You can make football safer.”

Steve Stepp, the head athletic trainer at Wesleyan School, in Norcross, is sold on the concept.

Stepp says the school required the Guardian Caps in practice for football players from 7th grade through 12th at the suburban Atlanta private school.

“The Guardian cap has been very effective at our school,’’ Stepp says.

The caps are lightweight and don’t retain warmth, making them comfortable for players to use, he says.

While some people have liability concerns, Stepp says, “parents see us as being proactive.’’

He says he’s encouraging other schools to use them. And he, like Peterson, predicts they will eventually be used in games, and not just practice.

“There will come a day when you see football teams playing with them on Friday nights,’’ Stepp says.

The HBO film “Mary and Martha,” starring Hilary Swank (right) and Brenda Blethyn, had an Atlanta premiere at the Carter Center. Photo credit David Bloomer

In 1946, the federal government established a new public health center in Atlanta to fight malaria. The disease was still a problem in the United States, and the South had the highest rate in the nation.

The new organization, the Communicable Disease Center, helped eliminate the malaria threat in the United States. But the center continued its disease-fighting work – and eventually became the current CDC.

Atlanta remains pivotal in the fight against malaria. The CDC is still working on the disease, tracking 1,500 cases each year in the United States, mostly in returning travelers and immigrants. The agency collaborates with foreign governments and other partners to fight malaria overseas, and conducts research.

A Carter Center program fighting malaria in Ethiopia and Nigeria has helped distribute nearly 14 million insecticide-treated bed nets in the two countries, among other activities there.

Given all that history, the Carter Center and Atlanta in general were natural sites for a screening this week of “Mary and Martha,’’ an HBO film focusing on malaria. It will have a national airing Saturday night on the cable channel.

The fictional movie portrays the story of two women, an American interior designer and a British housewife, who lose sons to malaria in Mozambique, a nation on the southeast African coast. Oscar winner Hilary Swank plays Mary. Brenda Blethyn plays Martha, whose story was inspired by Jo Yirrell and her son Harry Yirrell, who died after he volunteered in the West African nation of Ghana.

Spread by mosquitoes

Former First Lady Rosalynn Carter, with former U.S. President Jimmy Carter, gives a bed net to a Ethiopian woman in 2007. Photo credit: The Carter Center/L. Gubb

Malaria is a preventable and treatable disease, but it remains deadly. In 2010, it killed more than 650,000 people, 90 percent of them in Africa.

The majority of victims are women and children under 5 years old.

It is transmitted from person to person by the female Anopheles mosquito. This insect bites only at night, which is why mosquito nets over beds have long been used to protect people in high-risk areas.

(The name “malaria” derives from the Latin words for “bad air,” because for centuries people thought the disease was caused by the swamp gases found in many areas where mosquitoes breed.)

The disease infects the liver and red blood cells, causing high fevers, body-shaking chills and flu-like symptoms.

The film “Mary and Martha” underscores the importance of funding for mosquito nets, which cost $10 each. That’s not a lot of money by U.S. standards, but it’s a substantial sum in many of the poor areas where malaria is widespread.

The Atlanta premiere was presented by HBO and advocacy group Malaria No More, in partnership with the Carter Center’s malaria control program and the Emory Institute for Developing Nations.

The institute, a partnership between Emory University and the Carter Center, is co-hosting a conference this month in Atlanta on disease elimination and eradication. Malaria is a new focus for the institute.

Multipronged approach

The Carter Center began its work against malaria several years ago when it was fighting river blindness and other diseases in Ethiopia.

The center’s work in that country – where malaria is the leading cause of death – has proved successful, said Paul Emerson, the co-director of the Carter Center’s malaria control program.

Nigeria, the most populous African nation, is a much more difficult challenge, he told GHN before the film’s screening. “Malaria is endemic there – it’s very difficult to get much traction.’’

Emerson emphasizes a multipronged approach to fighting the disease, using nets and mosquito spraying, and providing timely diagnosis and treatment. Anti-malarial medications can also be used to prevent the disease.

Without a vaccine, “we have imperfect tools,’’ Emerson said. But using those tools effectively, he added, “may actually be enough.’’

The U.S. government is putting $1.6 billion into malaria control, he noted.

Emerson grew interested in fighting malaria when he volunteered as a young man in the Gambia, a small nation in West Africa, and saw two young children die of the disease.

“This is what really cemented in me the desire to work in malaria,’’ he said.

“No one should have to go through that. There’s no reason anyone should die from this disease.’’

At Gateway Jewelry and Pawn in Athens, the most sought-after items are guns

Over the years, Michelle Tenorio has seen all kinds of people buy all kinds of things.

At her store, Gateway Jewelry and Pawn in Athens, Tenorio sells jewelry, electronics, musical instruments and a range of other goods. But the store’s most sought-after items are guns.

The purchase of those guns potentially could come at a much higher price than the one on the tag hanging from its barrel.

“We’ve had a customer come in, just seemed completely normal,” she said, “and he got into a taxi going home and was playing with the gun,” scaring the driver. The driver immediately called the police.

The gun was confiscated by local authorities, who then discovered that Tenorio’s customer had a history of serious mental disorders.

Under federal law, it is illegal to sell firearms or ammunition to anyone whom the seller knows to have or has reasonable cause to believe “has been adjudicated as a mental defective or has been committed to any mental institution.” But Tenorio had no way of knowing about this buyer’s mental history.

Merchants try to comply with current law and keep guns out of the hands of dangerous people.

Pawn shops like Gateway require customers to fill out a Firearms Transaction Record. Once the forms are filled out, the clerk types the buyer’s information into the National Instant Criminal Background Check System database, a program created by the FBI to determine whether a buyer is eligible to buy firearms or explosives. Minutes later, the person’s criminal history and approval status show up on the computer screen.

The buyer’s mental health status, however, does not show up on the background check. That form of screening does nothing to prevent a person with mental illness from purchasing a gun.

That leaves Tenorio and others like her to rely on their personal judgment to make up for what the databases lack. Tenorio is within her legal rights to refuse to sell to a person who appears worrisome, but in doing so she has to rely on her gut feeling, and that is not foolproof.

“We go for the criminal background, so if they come back clean, there’s no way of knowing” about possible mental problems, she said.

Advocates for people with mental illness, meanwhile, emphasize that people with mental health conditions are no more likely than others to commit homicides or other violent acts. Most violent crimes are committed by people who do not have a mental illness, the advocates say.

Complicated legal issues

Attorney Jason Sterzer is interested in the delicate balance between adequate gun control and the public’s constitutional right to bear arms — especially since the mass shootings at Virginia Tech in 2007 and in Tucson, Ariz., in 2011.

When those massacres were reported, Sterzer was immediately bothered by the fact that both shooters, despite well-documented histories of threats and bizarre, menacing behavior, were able to purchase guns legally.

“In my view, the most crucial thing to understand about firearm regulation is that more regulations targeted at the law-abiding general public or regulations targeted at the type of weapon will not solve the problem,” said Sterzer, who wrote about these issues in the March 2012 issue of The Journal of Legal Medicine. “The solution, rather, lies in identifying those who would use the weapon to commit crimes and preventing them from gaining access to firearms.”

Sterzer’s research reveals a seeming paradox: States with the most restrictive gun laws have the highest rates of gun murders.

These crimes, he emphasized, are often committed by people with no history of mental illness.

“A blanket federal gun ban on mental disorders would not be fair,” Sterzer said. It would be a great injustice to strip constitutional rights from people who’ve been labeled as having depression or other common emotional disorders, he said. “This is not the answer. Rather, lawmakers have looked and should continue to look at whether the individual is a danger to themselves or others.”

Stricter state and federal regulations, Sterzer says, are not the best way to do it.

“More firearm regulations does not equal less firearm violence,” he said. “States which have the tightest gun control laws have the highest murder rates by firearms. Smart laws and effective implementation of those laws will make a difference.”

Gun rights efforts

Gun control advocates are not the only people pushing their cause. In some states, there are efforts to expand gun rights.

Last month, the Georgia House approved legislation that would allow individuals who have been voluntarily admitted for inpatient mental illness or substance abuse treatment to get a gun license.

The bill, which was supported by the state gun rights organization GeorgiaCarry.org, would have required officials to check whether applicants have ever been involuntarily committed for mental health treatment in the past five years.

Under the legislation, judges would be given the power to grant a license to anyone who has sought treatment, voluntarily or not. The bill would require applicants to authorize the release of their treatment records and provide recommendations from their providers. The involuntary treatment records would then have to be entered into a database. Judges would have to run checks, using the information in the database, before issuing a license.

Also under the bill, a person currently being represented by a guardian or conservator due to a mental illness, or who has threatened others in the past five years, would be banned from purchasing a gun.

The bill gained considerable support but ultimately did not win approval of the full Legislature. It died on the last day of the General Assembly session over a provision to allow guns on college campuses.

In the wake of the 2012 Connecticut school massacre, President Obama has proposed national legislation on gun control. Those proposals include bans on certain weapons and expanded background checks to prevent firearms from ending up in the hands of criminals or people with mental illness.

Political analysts say expanded background checks are more likely to pass Congress than weapons bans, because polls indicate that expanded background checks have greater public support.

But under current background check laws, Tenorio, the pawn shop owner, believes that relying on her gut may be her best line of defense against selling guns to people who appear to be dangerously mentally ill.

Alicia Smith is currently pursing her master’s degree in Health and Medical Journalism at the University of Georgia.

MedLink, one of the state’s largest FQHCs, has 10 locations in northeast Georgia, including this facility in Colbert

Federally funded community health centers provide free or low-cost care to people who might otherwise go without.

According to the most recent estimates, more than 300,000 patients received care from Georgia’s 27 federally qualified health centers, or FQHCs, in 2010.

These centers have a reputation for being no-frills places with few amenities.

That reputation may be due for an update. Though FQHCs would hardly be thought of as fancy, in some cases they offer conveniences that private practices do not.

MedLink, one of the state’s largest FQHCs, with 10 locations in northeast Georgia, has after-hours clinics for people who can’t miss work to see the doctor.

The health centers in rural regions often use telemedicine to diagnose some ailments, giving the patients access to specialists who can only be found in metropolitan areas. Some clinics use Skype or telephones to provide psychiatric services for people living in rural areas as well.

The people they serve are grateful. A nationwide study of low-income patients showed that those cared for in FQHCs are much more satisfied with their care than people who see doctors in other settings.

This is one of several important findings from the newest in a series of studies carried out by Dr. Leiyu Shi, director of the Johns Hopkins Primary Care Policy Center. He is an expert on the role the centers play in broadening access to health care and improving health outcomes throughout the population.

A model for other facilities?

Whatever it is that’s increasing patient satisfaction at these clinics may offer a lesson for providers in other settings, which will be increasingly important as the Affordable Care Act takes full effect in 2014.

The advent of the ACA and the continued alarm about the soaring costs of health care are shifting the focus from the quantity of care to its quality. For example, some provisions of the law will reward health care providers for providing better care, not for providing more services.

Another section of the law is spawning Accountable Care Organizations, designed to coordinate care and keep patients at home and not in the hospital, which is also expected to help lower costs.

“If the health center model is used as a mainstream provider, health care spending should decline,” Dr. Shi said. The study also shows that the centers’ quality of care is good – bolstering claims made by clinic administrators.

“Our goal is to provide primary health care to anybody that needs a medical home,” said Angela Rouse, director of business and community outreach for MedLink. According to Rouse, anybody includes people with no insurance, the best insurance, and everyone in between. Rouse works in MedLink’s Colbert office.

MedLink emphasizes long-term solutions over short-term fixes, said Rouse, emphasizing risk reduction and setting price expectations up front rather than waiting until a heart attack or other crisis happens.

The high level of satisfaction expressed by community health center patients surprised Shi and his team of Hopkins researchers. These clinics are not lavish by ordinary standards, and they are often found in areas where patients must overcome difficult personal circumstances, such as lack of transportation, to obtain health care.

Typically these clinics are in inner cities or extremely rural areas, where access to medical care has often been limited and sometimes non-existent.

A few years ago, MedLink conducted a patient satisfaction survey and recorded exceptionally high satisfaction scores despite long waiting times. Follow-up interviews revealed that patients were happy with the centers because of relatively modest things, such as a waiting room with air conditioning and television and a friendly staff.

“Their perception is we were meeting a need,” said Rouse. One-third of the patients at MedLink are uninsured, and air conditioning and TV are luxuries for some. Knowing this makes Rouse hesitant to put too much trust in patient satisfaction surveys.

Although Dr. Shi’s study shows high rates of patient satisfaction among community health centers, an evaluation of the care provided by Georgia’s FQHCs last year was not as favorable.

Georgia ranked near the bottom on four quality measures of care, including percentage of children who receive all seven federally recommended vaccines by age 2; percentage of adults — ages 18 to 85 — with hypertension who have their blood pressure under control; percentage of low-birthweight babies; and percentage of women — ages 24 to 64 — with at least one Pap test in the past three years.

Striving for improvement

After an article on the health centers in Kaiser Health News last April, Duane Kavka, executive director of the Georgia Association of Primary Health Care, told GHN that the 27 community health center organizations in the state are working to become ‘‘patient-centered medical homes.’’

“We’ve got to do better,’’ he acknowledged. Kavka also noted that the patients who get services at the clinic are ‘‘a population that no one wants to see.’’

Dr. Shi’s studies are ongoing, and he intends to dig deeper into patient satisfaction, so he can tell the difference between a fondness for air conditioning and actual quality-of-care measures.

He believes strongly in integrating preventive care and other services into people’s daily lives and community experience.

Rouse agrees, saying that every successful health center she can think of is actively involved with its community.

In the spacious waiting room of the MedLink Clinic in Colbert, an educational program about diabetes, a problem shared by many of the clinic’s patients, plays on a large TV screen.

Med Link’s communication strategy is simple and familiar: Knowledge is power.

“We’re the Home Depot, we’re the Lowe’s. We give you the tools, and what you build with those tools is up to you,” Rouse said.

Ian Branam is a freelance health and science writer currently pursuing a master’s in health and medical journalism at the University of Georgia. Ian has bachelor’s degrees in history and psychology from the University of Georgia. He is particularly interested in writing about public health, epidemiology, and the environment. Follow on Twitter as @ianbran6