by Katie Baker
ETSU College of Public Health
Appalchia/ASPIRE Scholar

My internship with the Tennessee Cancer Coalition (TC2) is going very, very well!  I have made significant progress on the skin cancer prevention toolkit through consultation with experts in the TC2 – Jackson region, the TC2 Skin Cancer Resource Committee Chair from Knoxville, and one of my local supervisors who represents the American Cancer Society.  I will be contacting a melanoma survivor from Appalachia as well as a local high school health educator in the coming days in an effort to incorporate their input and experiences into the program as well.  Additionally, we will be adding another sun safety awareness event to our schedule.  On July 16^th, we will provide no-cost educational materials and sun protection aids (i.e., visors, SPF 15 sunscreen, etc.) to those participating in health screenings during the Johnson City Farmers’ Market.

TC2 Summit on Cancer in Tennessee

June 16^th & 17^th, 2011

Franklin, Tennessee

As a part of my internship experience, I was invited to attend TC2’s 2011 Summit on Cancer in Tennessee which brought together researchers and academicians, physicians, nurses and other allied health professionals, cancer registrars, employers, health education and outreach professionals, community organizations, legislators, patient navigators, grassroots advocates and volunteers, and cancer survivors to focus on transforming the latest knowledge into strategies that communities, institutions, businesses, and individuals can employ to reduce the cancer burden in our state. 

I attended several interesting sessions, which I will describe below, and I even won first place in the Student Poster Competition for my poster titled, “Skin Cancer Prevention in Young Women: Evaluating a Measure of Pathological Tanning.”  The poster highlighted the prevalence of indoor tanning dependence and abuse among a sample of college undergraduates as determined by the Structured Interview for Tanning Abuse and Dependence (SITAD).

Pre-Conference Melanoma Workshop

When reviewing the Summit program, I was thrilled to see a pre-conference workshop on skin cancer.  During this session, we heard from Tara Bankes, a pathology assistant with Knoxville Dermatopathology Laboratory (KDL), Dr. Roy King, a dermatologist with KDL, and Richard Boland, a melanoma survivor. 

From Tara, I learned that 90% of skin cancer cases are caused by UV radiation and that 1 in 5 people (1 in 3 Caucasians) will be diagnosed with some form of skin cancer during their lives.  She also pointed out that melanoma, the deadliest form of skin cancer, is most common among 25- to 29-year-old females.  She took us through the ABCDs of melanoma detection, which stand for: Asymmetry, Border Irregularity, Color, and Diameter, adding an E to the acronym, which stands for Evolving.  Dermatologists believe the “evolution” of moles may be the most tell-tale sign of melanoma development and tell patients to pay particular attention to any changes in size, shape, color, elevation, bleeding, itching or crusting.  Tara stressed the importance of skin cancer prevention with the message to COVER UP YOUR SKIN with SPF 30 sunscreen and lip balm, hats, sunglasses, and umbrellas and to limit sun exposure between the hours of 10:00 AM and 4:00 PM.  She also emphasized that sufficient levels of Vitamin D can be acquired by spending just 15 minutes in the midday sun, and that sunless tanning products (i.e., spray-on tanning, self-applied lotions and creams) are the way to go for people desiring a tan.

Dr. King shared his work on the development of a melanoma database for Knox County.  He and his team have compiled over 6,000 cases from the area and have come to several conclusions:

• From 1998-2007, there was an 82% increase in the incidence of invasive melanoma.
• Melanoma incidence is 46.8% higher in 20- to 29-year-old females when compared to males in the same age group (likely attributable to tanning beds).
• There are more tanning facilities per capita in Knox County than in almost any other city in the country, and the prevalence of tanning among middle schoolers there is 15%.

HPV Vaccination in Appalachia

I also attended a session during which two  ETSU professors presented their work on HPV Vaccination in Appalachia.  Dr. Sadie Hutson of the ETSU College of Nursing and Dr. Kelly Dorgan of ETSU’s Department of Communications reported on their study in a presentation titled, “Beliefs and Knowledge of HPV and Cervical Cancer in Appalachia.”  Here, I learned that Appalachian women face an excessive cancer mortality risk and that 18- to 24-year-olds in this region are surprisingly unaware of HPV.  Drs. Hutson and Dorgan conducted interviews and focus groups in Northeast Tennessee and Southwest Virginia and came to the following conclusions:

• Appalachian women face an HPV Vaccination Protection Dilemma, where they perceive two types of “threats”: 1) unknown side effects that potentially outweigh the benefits of avoiding cancer; and 2) non-vaccination and the acquisition of cervical cancer.
• Limited knowledge, skepticism with regard to HPV vaccine commercials, and confusing risk all interplay to keep Appalachian women locked in the protection dilemma.
• Appalachian women often operate in “spheres of silence,” meaning that HPV and the HPV vaccine are not discussed by (1) providers and/or (2) the community.

by Brande Jackson

We are very proud to be back out with Brad Paisley on his H20 Tour again this year. Our first stops in Virginia Beach, Hartford and Cleveland were a hug success; we talked to lots and lots of country fans about the importance of clean water. As always, we were impressed by how engaged fans were in our project, and how eager they were to help. Our first three shows were a big success, and we are very excited about the remaining dates over the course of the summer. 

Like last year, we are also using our work with Brad to provide unique volunteer opportunities for those interested in this issue. By volunteering, you are not only contributing to your community (and getting a free Brad Paisley show as a thank you!) but demonstrating first hand the idea that a ‘small drop can make a big ripple’! To learn more about volunteering and to get signed up, visit:

http://www.waterequalshope.org/volunteer 

We also made a stop at Bonnaroo Music and Arts Festival this year as well. We were joined by a stellar team of 7 volunteers: Slidana, Jason, Jeff, Sarah, Krystina, Ralph and Audoin. Our team worked very hard in the infamous Bonnaroo dust and sun to educate Bonnaroo fans about why clean water is so important, and what role they can play in bringing it to those who lack it. By the end of the dusty weekend, we had talked to over to 500 Bonnaroo attendees about this important issue, and raised money that will go towards a new well building project - something Bonnaroo fans can be very proud of! 

In the months ahead, we’ll be making stops in Texas, Darien Lakes, Chicago, Tampa, DC, Philly and many other cities. We’re always looking for some volunteer support; visit the Water = Hope website to learn more.

by Emma Apatu
ETSU College of Public Health
American Samoa

Photo: Dr. Aga, (preceptor; Emma Apatu, Kasie Richards (East Tennessee State DrPH candidate); Aufa'i Areta, Associate Director/Acting Extension Program Coordinator)

Talofa (greetings)!  I arrived in American Samoa almost a week ago, and have fallen in love with the Samoan culture.  I have found the people to be very friendly, the fresh foods are delicious, and the oceanic and mountainous views to be postcard worthy.

 I have also been fascinated by the beauty of the traditional Samoan garb.   It is very common to find men wearing Lava Lavas which is a cloth like wrap skirt, and the women to be clad in beautifully printed dresses complimented by a flower in their hair.

 As I witness the beauty of this island, I have also taken note of the obesity problem.   It baffles me to see people of an island that has a plethora of nutritious food to have one of the world’s highest obesity rates.

The World Health Organization attributes American Samoan’s obesity problem on the fact that a great number of the people have stopped eating traditional foods and have adapted diets rich in processed foods.  A few days ago, I talked to some of the local people, and they also agree that a great part of the obesity problem is due to poor diet choices. 

Today I met with my field experience preceptors Dr. Aga and Aufa'I  Areta, at the American Samoan community college.  The meeting today was very productive and Kasie and I will meet with Dr. Aga and Aufa’I Areta who is the Associate Director/Acting Extension Program Coordinator later this week to finalize the scope of our community based Food and Nutrition project. 

by Shannon Langston
Department of Emergency Medicine
Vanderbilt Medical Center
Georgetown, Guyana

It usually comes to me in a super market, sometimes Wal-Mart.  This time, it was in a Chili’s restaurant in Miami International Airport.  I was returning from 6 weeks in Guyana and the bustling airport led me to seek refuge in a restaurant.  The burger I ordered, with a thick slab of bacon, nearly overcame me with emotion.  It wasn’t that it was such an incredible burger. It was my reflection, the contrast, of the place I often take for granted and the place I was returning from.   The excess we have become accustomed to.  Something so simple as a good burger is not obtainable everywhere.  Many things aren’t. 

The Emergency Department at GPHC, Georgetown Public Hospital Corporation, the country’s tertiary care facility, is busy.  It sees about 70,000 patients per year.  The House Officers and Residents work tirelessly to sort the truly ill from the baseline chronic disease present in the population.  I spent the majority of my time consulting on patients, standing at the bedside, and teaching the Emergency Medicine Residents and House Staff alike on the care of acute and chronic illness.  Often, as I went through the differential diagnosis of the patient, I would realize, we might never discover the exact cause of the patient’s illness.  Many of the diagnostic tests so easy to obtain here, are simply not available.  Blood cultures, to determine the infectious bacteria of a septic patient, aren’t easy to obtain.  A CT scan of the head, often ordered to excess in the US, is expensive for the population of Guyana, sometimes costing a months salary for a test that may be negative or have little impact on a patients’ subsequent care. Cardiac enzymes, used to diagnose heart attacks, aren’t readily available.  And, even if they were, neither is a catheterization lab.  I had to ask myself often where to draw the line between teaching good care and teaching appropriate care. 

The patients presenting to the emergency department in Guyana are often complex.  In addition to the ills that face patients in the US, tropical disease such as Malaria, Dengue, and Typhoid are present, complicating the clinical picture.  One child in particular nearly died from something so simple as touching a caterpillar, the most toxic known.  TB was a common complaint and is seen daily at GPHC, often in advanced stages.  At times it seemed as if the taxi drivers are actually aiming for the children as they make their way to school, so common is their appearance in the trauma bay with broken bones and head injuries.  Those injured in the interior, the jungle, often have to endure many hours over rough inland roads, or a choppy river, to reach the hospital.  I was often surprised by their survival and endurance of what must be agony, only to be gracious for the care provided.  Those intubated in the emergency department are ventilated by hand until a ventilator can be found in the ICU, sometimes hours later.  The nurses often take turns ventilating with few complaints. 

As I choked down my burger, I thought back to the infant with meningitis, gasping for air.  There was no spinal needle for children that would allow a lumbar puncture.   Despite aggressive treatment and antibiotics, the baby succumbed, as did another a few days later.  I recalled the young lady that presented with mild confusion and fevers.  In a matter of a few hours she was unresponsive with a dangerously low blood pressure.  I spent hours at her beside with the residents, struggling to keep her alive, without the rapid tests that would give me the cause.  One resident intubated and another started a central line.  Fluids, antibiotics, and multiple drips were started.   A lumbar puncture and an ultrasound were performed.  We wracked our brains to discover the missing piece of information that would keep her alive, a diagnosis that fit.  Her husband, whom I kept updated, was brought into the room.  I told him she was gravely ill, and would not likely survive.  I encouraged him to talk to her and say anything he wanted.  He whispered into her ear and kissed her on her cheek before walking away, sobbing.  Our efforts were not enough.  She died a short time later. 

Despite the challenges and material limitations, the physicians are eager to learn.  Suggestions to improve care are readily embraced by residents and management and solutions are sought to overcome an often challenging work environment.  In my short time there, through the work of many people, I was able to secure a readily available supply of much needed blood for trauma patients.  A resident is now teaching the calculated administration of vasopressors to other interns and sharing new knowledge to improve patient care for the local population.  By saving patients that would have died just a few years ago, they are learning to be hopeful as they provide compassionate care.   These things, it seems, are available everywhere