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A study in gratitude: Former patient helps out at free dental clinic

A free dental clinic last weekend in Perry treated more than 2,000 patients.

A free dental clinic last weekend in Perry treated more than 2,000 patients. Photos courtesy of the Georgia Dental Association.

Doug Taffe of Fort Lauderdale, Fla., traveled hundreds of miles north to central Georgia over the weekend to work as a volunteer at a free dental clinic.

His volunteer stint at the event in Perry was a form of repayment.

Two years ago, Taffe was in a motorcycle accident and sustained severe damage to his teeth. He couldn’t afford the extensive repairs. He heard about a Georgia Dental Association free clinic in Norcross, and traveled to the Atlanta suburb to see if he could get some work done.

“I looked like a homeless person,’’ he told GHN. “I couldn’t smile, had difficulty eating.”

GDADentists at the clinic pulled about a dozen of his teeth and gave him a denture.

So, out of gratitude, Taffe joined the volunteers in Perry delivering dental care to more than 2,000 people Friday and Saturday.

The Georgia Mission of Mercy is an outreach program of the Georgia Dental Association and its Foundation for Oral Health. It’s held every two years.

This was the first time the clinic was held in Perry. Previous ones were in metro Atlanta.

“We’re trying to move it around the state’’ to reach more people, said Frank Capaldo, executive director of the Dental Association. One big plus for Perry is that it’s near the geographic center of Georgia.

 

A lack of dental coverage

 

The services provided at the temporary clinic included cleanings, fillings and extractions. More than 600 dentists volunteered, along with 1,200 health care providers and community volunteers, including dental hygienists, lab technicians, pharmacists and local residents. And there were more than 100 dental chairs in use.

Each patient got a basic health check-up before being moved into one of the chairs.

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Taffe’s volunteer work consisted of briefing and advising the patients who were getting partial dentures. “I explain to patients how to care for dentures, what you can and can’t do,” he said Saturday.

Chris Harris, a 40-year-old man from coastal Georgia, had to have 11 teeth pulled and was fitted Friday with a temporary, partial denture, the Macon Telegraph reported.

When he looked at his reflection and his new smile, Harris said, it almost brought tears to his eyes, according to the Telegraph.

Roughly 20 percent of Georgians have no health insurance at all. But a much higher percentage, including those who do have some insurance, lack dental coverage. It’s increasingly common for health insurance coverage not to include dental care.

Frank Capaldo

Frank Capaldo

Oral health, however, is not just a medical side issue. Many people who skip the dental work they need will eventually wind up in a hospital emergency room.

In 2007, there were about 60,000 visits to Georgia emergency rooms for “non-traumatic” dental problems — oral health issues not caused by injuries. That cost more than $23 million.

The problem is not a lack of capacity in the system. Capaldo emphasized that most dentists in Georgia have the ability to see more patients in their regular practices.

Barriers to patients getting needed work, he said,  include lack of money, lack of transportation, an inability to get time off from work, and the Medicaid program not covering regular dental care for adults.

“We have people calling in, asking for free care,’’ he said. “We’re trying to get that messaging out.”

“The need for a dental home [for more patients] is great — no question about it.”

The Georgia Dental Association has a toll-free number for patients to call, 1-800-432-4357. GDA also provides a list of charitable clinics offering care: http://www.gadental.org/ charitable-clinics.html

Patients can also inquire here to find a dentist: www.mouthhealthy.org/en/find- a-dentist.

 

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Metro Atlanta at the center of a burgeoning HIV crisis

The Ponce de Leon Center, an HIV/AIDS clinic in Atlanta run by Grady Health System, is a one-stop shop for patients.

The Ponce de Leon Center, an HIV/AIDS clinic in Atlanta run by Grady Health System, is a one-stop shop for patients.

 

“The night I found out, I slept one and a half hours,” recalls D, a 29-year-old black gay man.

He’s talking about being diagnosed with HIV, the virus that causes AIDS.

“Even though I work in public health and tell people daily that HIV is not a death sentence, that first night that’s all I could think of,” says D. “This has to be wrong, I thought. I work in public health. This can’t happen to me.”

D, who requested anonymity, says he contracted the virus when a condom broke during sex. Two weeks later, he was tested for two sexually transmitted infections (STIs) – chlamydia and gonorrhea – but not for HIV. Shortly afterward, he went back for an HIV test and found out that he had the virus.

Soon after his diagnosis, D moved to Atlanta, which also happens to be the epicenter of a re-emerging national HIV crisis.

According to the latest CDC HIV surveillance report released this spring, metro Atlanta has the fifth-highest rate of new HIV diagnoses. And that statistic may understate the problem. Patrick Sullivan, an Emory researcher and former CDC director of HIV surveillance, says, “Atlanta has one of the most intense epidemics in the country.”

Three of the five core metro Atlanta counties – DeKalb, Fulton and Clayton – are among the top counties nationally in rates of new HIV diagnoses.

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What sets Atlanta’s epidemic apart, says another Emory researcher, Travis Sanchez, is how severely the new diagnoses are concentrated within a specific population: young black men who have sex with men (MSM).

The combined problems of poverty and lack of access to health care in Atlanta are the driving forces behind the HIV epidemic, and they disproportionately affect the black community in Atlanta, experts say.

“We think that HIV is no longer a death sentence, and in the era of antiretroviral drugs, we think that no one is dying,” says Emily Brown of the LGBT advocacy group Georgia Equality. “But the reality is that in the black community, HIV is advancing to AIDS for many, and people are dying. No one is talking about it.”

Atlanta is home to a large black gay population, a community in which transmission of HIV is high. Also, a recent study by the Brookings Institution, a Washington-based think tank, found Atlanta to have the highest income gaps between rich and poor, and many whose income is below the poverty line do not have access to health insurance. Georgia has among the highest rates of uninsured residents in the United States, and has rejected Medicaid expansion under the Affordable Care Act.

In 2013, Fulton and DeKalb counties had the highest number of people living with HIV diagnoses in Georgia – 14,695 and 6,116, respectively. These two counties also had the highest numbers of new HIV diagnoses in Georgia, with Fulton at 667 and DeKalb at 414, according to the latest figures from the Georgia Department of Public Health.

Public Health says that while there is cause for concern about the increase in HIV cases, the change may come partly because we’re getting better at tracking the number of infections. A more comprehensive reporting system has resulted in more accurate reporting of HIV cases to the CDC, state officials say.

 

‘We lack support’

 

Understanding why the black MSM community in Atlanta is so heavily affected by HIV remains at the heart of Sullivan’s and Sanchez’s research.

“Nationally, 1 in 4 new diagnoses of HIV are coming from young people, primarily gay men or MSMs, between the ages of 13 to 24,” says Sullivan. “Furthermore young black gay men bear the greatest burden of disease, accounting for twice as many diagnoses as white or Hispanic counterparts.” The same trend is likely present in Georgia, he adds, and it could be even worse than elsewhere.

Since 2010, with the inception of AIDSVu, a mapping project led by Sullivan, researchers have worked closely with state and local health departments across the country to document the nation’s HIV crisis in the context of income and education, both of which are linked closely to the spread of the virus.

Lamar Yarborough

Lamar Yarborough

And research by Sullivan and colleagues Adam Vaughn and Eli Rosenberg found that black MSMs perceive more anti-gay stigma than their white counterparts. People’s concerns about being stigmatized may make it harder to reach them if they are in denial about their illness or if they lack support, says Sullivan.

“We lack support. Being gay is not accepted at all,” D says of being gay and HIV-positive in the black community.

He moved to Atlanta partly to keep relatives and friends back home from finding out he was HIV-positive. It was only this past Thanksgiving, 18 months after the original diagnosis, when D felt comfortable enough to disclose his status to his father. And at home, he says, he still puts his medications in other bottles so guests don’t accidentally find out what he’s taking.

“When you’re black, you go to black schools, stay in the same circles,” says Lamar Yarborough, a 23-year-old black man and community organizer who lives in downtown Atlanta. “Unless you break out, this is what you know.”

Yarborough was diagnosed with HIV just before his 18th birthday, after growing very ill and being admitted to the hospital. He found that in addition to being infected with HIV, which had progressed to AIDS, he also had Kaposi’s sarcoma, a virally transmitted cancer closely associated with AIDS. At the time of his infection, Yarborough says, he was sleeping with both men and women, and he’s sure that the disease was sexually transmitted.

“Getting diagnosed means that you are gay in the [black] community,” Yarborough explains. He recalls being shocked. “I thought, oh gosh, it must be the gay disease.”

But Sanchez emphasizes that any stigma associated with HIV does not explain the significantly high number of newly diagnosed infections – or the overall high incidence of the virus – in the black MSM community.

 

Poverty a barrier to care

 

Young black MSMs are more likely to come from poverty than their white counterparts, says Public Health’s director of health protection, Dr. Patrick O’Neal. Members of this group, if infected, would have greater difficulty affording the compulsory care they need to be healthy and continue with daily life.

“Initial linkage to care isn’t as disparate as the retention of care,” O’Neal explains. “To be on some HIV medications, you need to have a minimum intake of 500 calories per meal. You need good nutrition, you need housing, access to transportation, and you may need psychological or spiritual support.”

The lack of economic opportunity for some in Atlanta plays a large role in the transmission of HIV, says Dr. Carlos del Rio, co-director of Emory’s Center for AIDS Research and an infectious diseases physician.

Dr. Carlos del Rio

Dr. Carlos del Rio

“If you are poor, you don’t have a place to sleep, and you don’t have the means to feed yourself, HIV is not your priority,” says del Rio. This contributes to later testing, late-stage diagnoses and progression to AIDS, he explains. Radio station WABE in Atlanta reported recently that half the patients who test positive at Grady Memorial Hospital’s FOCUS HIV testing program already have full-scale AIDS on the day they are diagnosed with the virus.

“We need jobs, we need more education, and we need more information,” del Rio says.

But even D – who is educated, employed, has health insurance and has been very proactive about his care from the beginning – says he was surprised how difficult it was to get into care in Atlanta. “Here you have to follow 10 different steps to get an appointment,” he says.

D says Atlanta should be more strategic about quickly arranging care for people just diagnosed with HIV. “I know so many people who tell me they’ve spent hours waiting to be seen in a health department or public clinic,” he says.

 

Solutions across sectors

 

In the era of antiretroviral drugs, D is living proof of his mantra: HIV is not a death sentence. After discovering side effects from the first medication he was taking, D decided, in consultation with his doctor, to be placed on another one. Within six weeks of this switch, D says, his viral load went from above 100,000 to undetectable.

A recent study estimates the average lifetime cost of $326,500 for HIV-related care for a person diagnosed at age 35, with monthly costs ranging from $1,854 to $4,545.

Government programs like the Ryan White HIV/AIDS Program are in place to help those without health insurance or financial resources to pay for meds. And there has been some success in getting insurers to lower out-of-pocket costs for patients who purchase health insurance through the ACA’s marketplace. But a treatment regimen depends heavily on the stability of a patient’s life, and those in precarious circumstances are at risk.

For Lamar Yarborough, this is a daily reality. “I distinctly remember being in the ICU and being told my insurance had been cut,” he says. Now supported by the Ryan White program, Yarborough says he’s always had a backup plan for being able to afford his medication in case funding gets cut. He is enrolled in Job Corps, where is he completing his GED and developing skills in business administration. He will graduate from the program this month.

Yarborough strives to eat well and stay healthy. He is grateful for the care and support he has received from clinicians at the Ponce de Leon Center, an HIV/AIDS clinic in Atlanta run by Grady Health System. “I was at the Ponce Center every day for two years,” he says.

Dr. Patrick O'Neal

Dr. Patrick O’Neal

Clinics like the Ponce Center are key in moving treatment forward, says del Rio. Broadly defined as a medical home, the Ponce Center is a one-stop shop so patients don’t have to go from place to place to get what they need. The center is staffed with HIV specialists and professionals who are able to coordinate HIV care with any necessary counseling or mental health treatment as well as assistance for housing or financial aid.

O’Neal of Public Health says efforts at the state and federal level are well under way to increase access to HIV testing, initial care, and long-term care to high-risk minority populations. Georgia is one of eight states participating in the federally funded Care and Prevention in the United States Program (CAPUS).

This program has produced the Metro Atlanta Testing and Linkage Consortium (MATLC), which meets quarterly to coordinate and expand testing and care in high-risk areas across five counties in metro Atlanta. At the county level, del Rio mentions another group, The Fulton County Task Force on HIV/AIDS, which is trying to prevent transmission and spread of HIV by addressing things like public education.

Good solutions will come from across the sectors, bringing together community health and academic organizations, he says.

Still others say the matter is even more complex. The prevalence of HIV in the black gay community has deeper roots than just stigmatization, poverty, or the need to adhere to medication routines, says longtime Atlanta black LGBT activist and community organizer Charles Stephens.

Beginning with the 1980s epidemic, Stephens says, fewer resources were allocated to the black gay community due to disproportionate funding – the consequences of which the metro Atlanta community is facing today. “We can’t talk about HIV prevalence without talking about community institutions to foster resilience,” Stephens says.

 

‘Don’t touch me, I’m pregnant’

 

Research by Sullivan, Sanchez and their colleagues found that in Atlanta, young black MSMs experience a significantly higher incidence of HIV than their white peers. But that’s not because of more reckless behavior or greater promiscuity. Instead, the racial disparity is linked solely to health insurance status and the “partner pool,” the network of people an individual is likely to have sex with.

Travis Sanchez

Travis Sanchez

Among participants in the study, fewer black MSMs had health insurance than did their white peers, and having coverage affects access to broader STI testing as well as to HIV prevention services. The black MSMs were also more likely to have sexual partners who were themselves black MSMs. Because HIV is already so prevalent in this partner pool, the network of HIV transmission is strengthened with each interaction, Sanchez explains.

Sullivan, Sanchez and their colleagues suggest that in the fight to reduce HIV in Atlanta, there has been too much focus on behavioral interventions, such as getting individuals to use condoms and practice safer sex. These things are important, but the experts propose a shift of emphasis toward larger-scale biomedical interventions, such as promotion of HIV testing for at-risk youth as young as 15, as well as improving linkage to care.

Yarborough, HIV-positive for several years now, has faced a number of misconceptions around his diagnosis. “I’ve gotten from, ‘Don’t touch me, I’m pregnant,’ to ‘You don’t even look sick.’ “He says he was recently asked by a physician to refrain from playing contact sports with organized groups. And a nurse even asked that he put his used tissues in a biohazard bag. “If you’re not an HIV specialist, you’re ill-equipped” to help patients, Yarborough says.

Georgia is ranked fifth among the 50 states for incidence of HIV diagnoses. Statewide access to HIV specialists is even more problematic, with few HIV specialists to manage care of the currently 51,510 people in the state living with HIV.

Yarborough also thinks that current public health messages about prevention, such as campaigns advocating condom use, are not enough. He says the current approach indicates poor understanding by public health officials of the black community’s mistrust of the health care system and belief that blacks are marginalized.

Most immediately, D says, public health campaigns at clubs and restaurants need to be smarter and more explicit to get people in the gay black community to take action to protect their health.

Another strategy that D suggests is to encourage people who are considering becoming sexually intimate to get tested together first. “Condomless sex is thought to be bad,” he says. “But if you’re in what you think is a monogamous relationship, this is often a norm.”

 

PrEP: No magic bullet

 

Last year, the CDC introduced clinical guidelines for the much-talked-about PrEP – which stands for pre-exposure prophylaxis – an HIV prevention pill that can be taken daily by uninfected people who are at risk of being exposed to the virus. So far, studies have found that PrEP can reduce the risk of HIV infection by up to 92%.

The prevention method, seen in the form of the pill Truvada, can help reduce the risk of getting HIV by stopping the virus from taking hold. Truvada is an antiretroviral medication, and it is still mainly used on people who are already HIV-positive, because it limits the virus load.

Many insurers are willing to cover the costs of Truvada, but some require authorization before approving coverage, according to the nonprofit HIV/AIDS journal Positively Aware. Gilead, the maker of Truvada, also has a medication assistance program to provide access to the medication for those who are not insured as well as a co-pay assistance program for those who are insured. Without insurance, an individual can expect to pay more than $1,000 monthly.

D found out about PrEP shortly after he was diagnosed, and he says it’s a good idea. But he also thinks there needs to be more public education about it, and he would like to know more about the long-term effects of the drug.

Emily Brown of Georgia Equality

Emily Brown of Georgia Equality

“For individuals who are at higher risk and [HIV] negative, what other choice do we have?” he says.

Sullivan’s and Sanchez’s research suggests that administering PrEP on a wide scale to at-risk individuals could be very effective in cutting down the rate of infections in Atlanta. “There are implementation challenges but it’s not impossible,” says del Rio, who notes that the current funding structure for prevention doesn’t make this a viable option right now.

A clinic like the Ponce Center, he explains, receives funding only to treat patients who already have HIV and does not have the financial resources to administer a preventive measure like PrEP to HIV-negative patients. Unlike San Francisco, which was at the heart of the HIV epidemic of the 1980s and ’90s, Atlanta does not have its own city health department and would have to rely on coordination between county departments, adding to the complication.

And as many people who work on HIV care emphasize nationwide, Emily Brown doesn’t think that PrEP is a magic bullet or miracle drug for the HIV epidemic in Atlanta. With the barriers that many black MSMs already face in the way of access to HIV care, access to PrEP is just another hurdle, Brown adds.

“Right now it’s still unclear how PrEP is going to be available based on economic diversity,” says Brown. In Atlanta, Brown says, PrEP is still most easily accessible in private clinics, for those who have health insurance. For the black MSM community, the gap between eligibility for the preventive medication and actual uptake is wide. “Who is going to make this [PrEP] available to black gay men?” says Brown.

 

Innovative ideas

 

In addition to AIDSVu, Atlanta is one of the first three host cities for the HIV Continuum Map, another cutting-edge public health surveillance project that is able to break a city down by ZIP code to look not only at new diagnoses within a city, but also at late HIV diagnoses, what linkage to HIV care within a city looks like, engagement in HIV care, and viral load counts.

NHTD_poster“Maps are really powerful,” says Sullivan. “I really believe in the power of data for advocacy to direct programs better.”And that’s exactly what people like Emily Brown are doing. After establishing ACFLY, a group that meets regularly throughout the year to improve services for youths in metro Atlanta, last year Brown and her colleagues recognized the need for an HIV subcommittee to better address the needs of HIV-positive young.

And this April, she helped to launch the Youth HIV Policy Advisors Program, which will match 20 elected officials – ranging from city council members to U.S. and state representatives, school board members, prominent pastors, as well as allied health organizations – with 20 people under 30 who are living with HIV in metro Atlanta. The group will receive training throughout the summer before meeting with officials several times this coming fall.

“We want to set up a program where HIV-positive people can support each other at the policy and legal level,” says Brown. “We need a conversation around funding for research and development in HIV prevention. We need conversations around the root causes of youth HIV in metro Atlanta, including lifting needle exchange bans, improving sexual education and increasing housing and access to health care for those at highest risk.”

Community approach needed

 

While he believes that HIV is the moral issue of his generation, Stephens also places emphasis upon understanding and respecting the black gay community overall. He is founder of The Counter Narrative Project, a platform that seeks to change the conversation around black gay men by giving them a voice.

Charles Stephens

Charles Stephens

“Atlanta has such potential in leading the way and being innovative in how we reduce HIV prevalence in black gay men,” Stephens says.

In light of how HIV has affected him personally, Yarborough says the virus will remain a major focus of his life’s work. He recently founded H.Y.P.E., a nonprofit organization for youths ages five to 30 who are living with HIV.

“I was devastated when I got my diagnosis,” Yarborough says. “If I can help other people go through it, that’s what I want to do.”

D says he now feels he puts greater value on his own life. “I’m not the [sad] story you hear,” he notes. Instead, he’s had considerable success in his life. D bought his first home at 20 and is currently working on his third academic degree.

While the black community could use more role models, D admits that many higher-income individuals like himself live with HIV in silence because shame remains a barrier to honest conversations about HIV within the community.

“Making those who are HIV-positive comfortable enough to come out to a community which is supportive rather than blaming is another key to prevention,” D says. “In the future I see myself coming out,” he adds. “But it’s a process.”

 

Maithri Vangala is an independent journalist in Atlanta interested in health policy.  She was previously an editor at The Health Care Blog. You can follow her on twitter at @maithripriya.

 

Health officials in Athens go whole hog to collect data

roasting

A March pig roast at the West Broad Farmers Market helped collect health surveys from local residents.

On a recent Saturday, hundreds of Athens residents streamed through the gates of the West Broad Farmers Market.

The lure was roast pig and sides. The price of admission: A 10-minute survey.

The event’s purpose was to discover more about the health of the families who came to enjoy food, music and a good time.

The goal of this and similar events over the next few months is to collect information from 2,000 households in Athens – data that will be incorporated into a national database.

pigs

Noah Brendel, an Athens-Clarke County cook, volunteered to help roast and carve the 200-lb hog for the first roast.

The health needs assessment is a federal requirement for nonprofit hospitals under the Affordable Care Act. Hospitals must complete an assessment every three years.

Athens Regional Medical Center and St. Mary’s Health Care System enlisted Community Connection to carry out the task.

County Commissioner Melissa Link was on hand to welcome attendees. Like other volunteers, she helped people fill out the survey.

“It was the first day of spring, and it was beautiful,” Link said. “There was really a diverse crowd, and we were able to get information from people whose needs usually go unmet.”

The March 21 event was the first of four being hosted this spring by Community Connection, which operates Athens’ 211 helpline. The others are set for this Saturday, April 25, and May 9 and June 6 – each in a different part of Athens-Clarke County.

“When we entered into contract with the hospitals to do this needs assessment – to get the voices of the community reflected in this document that they’ve got to submit – we committed without knowing how we would deliver on it,” said Fenwick Broyard, executive director of Community Connection.

Broyard hit upon the idea of pig roasts as a way to bring together people of different ages, races and backgrounds – and to complete a large number of surveys efficiently. Apparently he was right: Participants in the first big party filled out 600 questionnaires.

 

A wealth of information

Although hospitals are charged with collecting this information, every health and social service in Athens-Clarke County will benefit from what the survey shows.

“We’re not just talking about data, we’re talking about holding a mirror up to ourselves, finding out what works, and discovering where each of us can contribute,” said Delene Porter, director of the Athens Area Community Foundation.

Delene Porter

Delene Porter

The fact that each roast will take place in a different part of the county increases the chances of attracting a broad cross-section of residents. And the range of sponsors signals that many organizations are interested in what can be learned. Athens Regional Health System, the Food Bank of Northeast Georgia, Watkinsville First Baptist Church and Athens Area Community Foundation are all involved.

The schedule is available at athenspigroast.com

Participants fill out their questionnaires before going through the gates, and volunteers will be available to assist them with the paperwork if necessary. Those who want to show up and join the feast immediately can go online and fill out the survey in advance. They’ll get a receipt that serves as a ticket to the pig roast.

The questionnaire asks for individual and household information, such as income and education. It also asks about health problems and access to medical care, mental health care and dental care, and about factors such as safe neighborhoods and full-service grocery stores. (The question about stores relates to the availability of nutritious food in a community.)

The answers to the questions should lead to more efficient use of public resources. Athens’ hospitals will know where to focus their resources based on the needs expressed in the survey.

“There isn’t a solid base of data the community can draw from in determining what its priorities are going to be,” said Broyard. “So we’d like to help the community identify for itself what the priorities are.”

 

Not your everyday meal

Pig roast attendees can’t be blamed if they care less about service planning and more about the savory aromas wafting from the whole hog. Chef Chuck Ramsey from Pulaski Heights BBQ is donating the pig to be roasted at each event, and other local restaurants are donating side dishes.

“Not very many people can roast a whole hog at home,” Broyard said, explaining the singular nature of the spectacle and how it brings out both the curious and the hungry.

focus group 1 picture

Fenwick Broyard (in background), executive director of Community Connection and coordinator of the Athens Pig Roast events, addresses a focus group.

“It’s a creative effort. I really enjoyed meeting new people, and this is a good opportunity for us to see what the strengths and challenges are in our community,” said Kirenna Gallagher, director of Family Connection in Oglethorpe County. She also helped people complete surveys at the first pig roast.

The next roast will be on April 25 at the East Athens Community Center.

“We didn’t have a strong representation from the Latino community at the last event, but we’re hoping that we will for this upcoming one,” Broyard said. “The East Athens community is one of the more underserved in Athens, so we’re looking forward to documenting the concerns expressed to us from these folks.”

Spanish-speaking volunteers will be on hand to assist with the surveys.

“We’ve gone out and gotten volunteers to help us administer the survey who are members of that community,” Broyard said. “There is a level of trust in the folks that are going to be helping.”

Locations for the May 9 and June 6 pig roasts will be announced soon and posted at http://www.athenspigroast.com. The survey is also available there.

 

Sydney Devine, from Valdosta, is currently a first-year graduate student in the Health and Medical Journalism program at the University of Georgia. She works as a research reporter for the university and is interested in health issues in low-income communities.

Will dental ruling send ripples through health care industry?

Georgia's 9,500 nurse practitioners include Dian Evans (left), specialty coordinator for the Emergency Nurse Practitioner Program at Emory University's Nell Hodgson Woodruff School of Nursing.

Georgia’s 9,500 APRNs include Dian Evans (left), specialty coordinator for the Emergency Nurse Practitioner Program at Emory University’s Nell Hodgson Woodruff School of Nursing. Photo credit: Bryan Meltz with Emory Photo/Video

A recent U.S. Supreme Court ruling about teeth-whitening services may have long-term implications for health care professionals and their practices across the country.

The dispute involves the right of dental hygienists to perform such services in North Carolina. The Federal Trade Commission brought a major anti-competition case on the matter. The high court did not settle the case, but rejected the state dental board’s claim that its actions were immune from FTC scrutiny.

“In this case, the North Carolina dental board’s members, primarily dentists, were drawn from the very occupation they regulate. They barred non-dentists [in this specific case, dental hygienists] from offering competing teeth-whitening services to consumers,” said FTC Chairwoman Edith Ramirez in a press release.

The American Nurses Association says the dental board case may have “far-reaching implications beyond dentistry.”

In Georgia, the experts are divided on how, or if, the case could affect professional practice laws.

What doctors and nurses say

Debbie Bartlett, CEO of the Georgia Nurses Association, says her organization “will utilize the Supreme Court’s ruling to help inform Georgia legislators about the need to support federal antitrust laws [as well as] avoid unduly suppressing pro-consumer competition.”

Georgia state practice and licensure law restrict the ability of nurse practitioners — nurses trained to perform many tasks often left up to doctors — to engage in at least one element of practice. Georgia nurse practitioners, also known as advanced practice registered nurses (APRNs), cannot write prescriptions for Schedule II medications. And their ability to order specific diagnostic tests is also limited.

The state requires supervision, delegation or team management by licensed physicians in Georgia in order for any nurse practitioner to provide patient care.

Donald J. Palmisano Jr.

Donald J. Palmisano Jr.

Donald J. Palmisano Jr., executive director of the Medical Association of Georgia, sees little reason for concern about the high court ruling, because the kind of situation cited in North Carolina does not exist here.

“The North Carolina case is drastically different than the way the licensing boards work in Georgia.” says Palmisano. Here, a board’s proposed actions are reviewed by the state attorney general’s office and released for public comment, he notes.

“The ruling in North Carolina never rose to the level where the Medical Association needed to contact the Georgia Nurses Association,” Palmisano says.

“The two organizations [in Georgia] have a fairly strong relationship. I don’t foresee [a big impact from the Supreme Court ruling] here,” he adds.

Atlanta nurse practitioner Mary Perloe agrees. “I actually think nurse practitioner collaborative agreements with physicians and using evidenced-based protocols make sense,” she says.

“I also believe that the nurse practitioners should bear responsibility for their practice. As NPs gain more authority, accountability needs to follow, and physicians need to be relieved of this liability,” says Perloe.

Rebecca Wheeler, the GNA past president, suggests the ruling may be a mixed blessing for those in the nursing profession.

“I think the decision is great for APRNs, but I am a little worried about what this means in order to protect our own RN scope of practice from medical technician or nursing assistant roles,” Wheeler says. “I feel like this is a bit of a double-edged sword for nursing.

“I’m not saying it’s necessarily a bad thing [referring to the Supreme Court decision]. We probably need to be prepared to ‘give a little’ if we want APRNs to be able to practice to the full extent of their training in Georgia.”

 

The issue of dentistry

 

The American Dental Association (ADA) said it was “extremely disappointed” at the U.S. Supreme Court decision.

The group said the decision “constitutes a dramatic departure from the Supreme Court’s established law, and throws into question the regulatory, licensing and disciplinary authority of thousands of professional boards across the county.”

“The ruling creates a quandary for professional boards . . . with no explanation as to what level of ‘active supervision’ is necessary to invoke immunity for each board,” ADA stated.

The association said it is planning to work with other organizations to provide some kind of guidance in view of the Supreme Court’s decision.

But among Georgia dentists, as among physicians in general, there seems to be less alarm about the ruling. Frank J. Capaldo, the Georgia Dental Association’s executive director, says there are a number of important distinctions between the dental licensing boards in Georgia and North Carolina.

“In Georgia, members are appointed to the Board of Dentistry by the governor, but in North Carolina they are elected to the board by other licensed dentists,” Capaldo says. “This difference in and of itself shows significant state oversight in Georgia.”

 

Some see more opportunities

 

Scope of practice limitations for nurses exist alongside a shortage of health care providers in Georgia, especially in rural areas.

The consumer group Georgia Watch recently reported that the number of licensed APRNs in Georgia has reached more than 9,500. With the physician shortage in the state, which is expected to get worse, APRNs could help fill this primary care gap, the group’s report says.

NP Photo with manA total of 129 of Georgia’s 159 counties have a shortage of health care professionals. In fact, about 80 percent of Georgia’s counties contain substantial populations without a consistent source for primary care, according to the Georgia Watch report.

Georgia Watch and others continue to urge state policymakers to consider using more advanced practice nurses and physician assistants in health care shortage areas.

Many Georgia physicians, however, traditionally support the restrictions on the duties of nurse practitioners. They’re concerned about whether people who are not doctors — working on their own — have the training to safely diagnose and treat patients, refer them to specialists, admit them to hospitals and prescribe medications for them. These doctors think the NPs should continue to work under the oversight of physicians.

The right of Georgia nurse practitioners to prescribe medications didn’t come until 2006. Georgia was the 50th state to grant NPs prescribing ability.

Many health care experts say that with the influx of thousands of Georgians into the health care system under the Affordable Care Act, the time may be right for the state to review its scope of practice laws, especially in rural areas.

“There are, after all, cost realities here. We just need to be prepared,” says Wheeler, referring to NP restrictions.

“This [Supreme Court] ruling seems to open up the door for everyone, including medical technicians or nursing assistants, as much as it does for APRNs,” she says.

 

Judi Kanne, a registered nurse and freelance writer, combines her nursing and journalism backgrounds to write about public health. She lives in Atlanta.

 

Understaffing among Georgia’s school nurses: A quiet crisis

School nurse Sally Boswell examines a Greene County student

School nurse Sally Boswell examines a Greene County student.

Sally Boswell is the first person many low-income families in Greene County call when their child gets sick.

She hears about everything from acute ear infections to chronic conditions such as diabetes. Boswell helps parents, grandparents or guardians decide whether their child needs to see a doctor.

She is the only school nurse for the county’s 2,300 public school students. Despite the long economic downturn and resulting budget cuts, she has stuck with her passion for nursing.

Greene County

Greene County

Thanks to Lake Oconee, built in 1979, historically rural Greene County has attracted tourists and some very affluent residents in recent decades. Today it is listed as one of the wealthier counties in the state, with a median income of about $42,500. But poverty remains, and the number of Boswell’s students who are on Medicaid or are uninsured is high.

School funding for nurses and health care workers in Georgia varies by locale. Georgina Howard, director of the School Health Nurse Program at the Georgia Department of Education, says, “In Georgia, we’ve made some progress, but we aren’t fully staffed.  It’s left up to the district how they want to do their staffing.”

The current recommendation from the National Association for School Nurses is to have 1 nurse per 750 students. Georgia’s 2,264 public schools serve 1.7 million students, so the recommended number of nurses for the state is 2,267.

But as of October 2014, there were only 1,555 licensed nurses who work in the state’s schools, Howard said. That leaves a shortage of more than 700.

Problems to confront

In neighboring Morgan County, with a median income at about $47,700, there are four nurses for about 3,200 students. “Morgan County has a school nurse at every school; primary, elementary, middle, and high school,” says Leah Ainslie, who worked in Greene County before she became the nurse manager for the local public health department in Morgan.

Many students at Union Point STEAM Academy have asthma or diabetes.

Many students at Union Point STEAM Academy have asthma or diabetes.

“[The] purpose of the school nurse is to keep children well, so the children can learn.  If you don’t have anyone there to do that, then the kids aren’t learning,’’ says Ainslie.

Being the only school nurse in Greene County, Boswell barely has time to drive 10 minutes between the county’s one pre-school, two elementary schools, one middle school and one high school. The constantly shifting medical needs of students dictate what she does from one day to the next.

“When I started, we had four registered nurses and we ran a program, a true comprehensive nursing program,’’ Boswell says. “We did things like CPR classes for the bus drivers, we were able to do certain programs for not just the students, but for the faculty.”

Now, her attention is solely focused on the health of the students.  In early February, the hot spot was Union Point STEAM Academy, a K-7 elementary school that focuses on science, technology, engineering, the arts and mathematics.

“I’ve got little kindergartners who are horrible asthmatics, and all of the diabetics at the elementary level are here,” Boswell says.  “I have to be here to do insulin every day.”

Every day is different, but busy

Between administering breathing treatments and monitoring insulin levels, Boswell uses her qualifications as a pediatric nurse practitioner.  She catheterizes a wheelchair-bound student, diagnoses an ear infection in another student, and lines up a doctor’s appointment for a third.

Boswell’s job has become much more than keeping kids well.

When a family member can’t come to pick up a sick child, she will even give the youngster a ride home (with parental permission,  of course).

On a recent morning at 8:30, students swarmed in and out of her small office.  One child’s arms were covered with what appeared to be insect bites, and an itchy and swollen rash was forming. Another was reporting for his asthma inhaler treatment, and two hovered over a single toilet for fear they were going to vomit.

“I am certainly the child’s advocate” on medical issues, says Boswell. “With 2,300 students and knowing their families, and where they come from . . . I think that I help the continuity of care.”

 

Ansley Stewart is pursuing her master’s degree in journalism at the University of Georgia.  She is a freelance writer, musician, and also works full time at UGA.  

 

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