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Listening to a recording of Big Joe Williams singing “The Sugar Diabetes Blues” (Got them sugar diabetes blues; somebody help me please. . . ) while zooming through the Mississippi Delta on Highway 61 is to be at the  intersection of what is the best and worst of this fabled landscape.

The Mississippi Delta blues, which spread northward and worldwide in the aftermath of the Mississippi River flood of 1927, is a uniquely American music form that gave rise to many other music types–jazz, rock and roll and most other forms of popular music.

Luther Brown, PhD, director of the Center for Delta Culture at Delta State University, called the Mississippi Delta the “birthplace of American culture, which owes its roots to the Delta land and the people who lived here.”

But the plantation system that allowed the cultivation of 5.5 million acres of some of the richest soil in the world also put in place the barriers that still have adverse affects on the health of the region’s poorest citizens.

Chip Morgan, executive vice president of the Delta Council, explained the Delta was largely uncultivated during the antebellum period. It wasn’t until the end of the nineteenth century and the beginning of the twentieth century that large tracts of hardwood forest were turned into farm lands. 

This immersion in Delta culture came courtesy of a bus tour of the Mississippi Delta sponsored by the Delta Health Alliance and the Diabetes and Metabolism Center of the University of Mississippi Medical Center (UMC). The bus trip brought together representatives of many organizations and institutions that are joining in a partnership to bring Delta residents better health.

Most of the Delta residents earn their living from the rich alluvial soil where cotton, soybeans, rice, corn and catfish flourish. “Forty one percent of the land area in the United States drains by Greenville, Mississippi,” Morgan pointed out. “If it snows in Montana or rains in New York, that water flows by Greenville.”

In some places, there is 85 feet of top soil. The fecundity of the soil hasn’t given rise to a healthy populace, however.

Dr. Karen Fox, COO of the Delta Health Alliance (DHA), said that people in the Delta aren’t just sicker than the other regions of the state.
“They’re a lot sicker,” she emphasized, pointing out the population in the 18 Delta counties (minus Desoto County that borders Tennessee and is part of the Memphis metro area) is 240,000 of the entire state population of 2.5 million. “If you eliminated the health statistics from the 240,000 Delta residents, Mississippi’s health status would rank around 25 instead of 50.”

The poor health of the region is an anomaly in a country whose death rates from cardiovascular disease and cancer are steadily decreasing. In a chicken-egg conundrum, the health status affects the economy that affects health status.

Dr. Cass Pennington, the DHA’s chief executive officer, says absenteeism in the workforce is a major impediment to economic growth in the Delta, and diabetes is one of the chief reasons for workers not working. But people in the Delta often work sick, too, noted Bill Triplett of the Delta Regional Authority (DRA). “We did a health screening at a big store and had to send 18 employees home because their blood pressure was so high.”

The forces for change began to coalesce around 2000 when President Bill Clinton established the DRA to spur economic development in the Delta counties of six states including Mississippi. In 2001, Sen. Thad Cochran created DHA to work with the existing Delta Council on problems of access to care and large scale public health education. DHA, according to Pennington, has in six years gone from $2 million in funding to $25 million, and from four large projects to 28.

Six years ago was also about the time Dr. Marshall Bouldin, associate professor of medicine at UMC and director of UMC Diabetes and Metabolism Center, began to see the fruits of a system of diabetes care that he began in 1999. Bouldin said his charge came from UMC vice chancellor Dr. Dan Jones who asked Bouldin to find a system that could be replicated in communities throughout the state to combat diabetes.

Diabetes hurts people, it hurts the workforce, and it costs this country $85 billion a year in total healthcare expenditures. 

Mississippi, where 11 percent of the population has diabetes, has the highest incidence of diabetes in the nation. The rate of complications–kidney failure, heart disease, blindness and amputation — is abysmal. And everything is worse in the Delta.

The system of clinics began at the Jackson Medical Mall Thad Cochran Center. Now the Delta Diabetes Project, under Bouldin’s direction, has clinics in Greenville, Yazoo City, Clarksdale and in the University Medical Pavilion at UMC. Another is planned at the Aaron E. Henry Comprehensive Health Center. The newest clinic partner is the Yazoo City Rural Health Clinic, where the diabetes clinic is directed by a longtime practitioner in the area, Dr. Marion Siegrest. Instead of retiring, the physician, now 77, decided he wanted to make an effort to curb the dreadful rates of diabetes complications in his community.

When the bus stopped in front of his clinic, housed in an old gas station, Siegrest told the group that he had practiced in Yazoo City for 45 years, and he was well aware of the toll diabetes took on his patients. 

“I wasn’t able to give the kind of time diabetes patients require,” he said, shaking his head.

The partnership with the Delta Diabetes Project gives him three nurse practitioners, a diabetes educator and a nutritionist who all come to the clinic once a week to work with patients under his direction.

Siegrest is hoping his clinic will duplicate the results in other Delta clinics, such as the year-old clinic in Clarksdale under the direction of Dr. Andrea Smith. During lunch at the Ground Zero Blues Club in Clarksdale, she told the group that her clinic had succeeded in reducing blood sugar levels by  two points—and right at the level recommended by the American Diabetes Association for optimum control.
The level of hemoglobin A1C determines a patient’s risk of complications. For every point reduction in the A1C level, a patient’s risk of complications is reduced by 35 percent.

But the success of the Clarksdale clinic isn’t unique in the Delta Diabetes Project. Of 5,000 patients in all clinics, the results have been consistent and durable, Bouldin said.

“We tell patients if they’ll hang with us for six months, they’ll see results,” he said. “They don’t have to accept bad outcomes.”

And best of all in Bouldin’s view is that there is no disparity in the results. The outcomes were statistically the same regardless of race, gender, socioeconomic level or ability to pay for services. Few centers in the country have reported outcomes as good as Bouldin’s, and especially not in the high-risk populations the clinics serve.

Bouldin’s data, which also showed lowered cholesterol, lower blood pressure, and better lipid control, has other researchers taking notice. Dr. Monica Peek, representing the University of Chicago Diabetes Research and Treatment Center, told the bus audience that her group is looking at projects all over the country to see what works and what doesn’t. “What’s going on here is very cutting edge and innovative, and we want to get that out to the rest of the country so others can duplicate it,” she said.

Dr. Darwin LaBarthe, director of the Division of Cardiovascular Prevention of the Centers for Disease Control and Prevention, said “Success here will have an impact on the rest of the country.” He also noted that the diabetes model could work for the long term care of patients with other chronic conditions such as hypertension, hyperlipidemia and obesity.

“The general feeling is if we can do it in the Delta and be successful, it can work anywhere,” said Bouldin. “We don’t do anything that’s revolutionary or high tech. We use all the tried-and-true methods of diabetes management.”

The most innovative technical feature of the system is telemedicine. The television hook-up between centers allows Bouldin to direct care from a distance. What is perhaps revolutionary is the absence of the traditional hierarchy of care, starting with the physician at the top and the patient educators and dieticians at the bottom.

“In this model, every professional role is critical,” Bouldin said. Nurse practitioners, RNs, diabetic educators, pharmacists and dieticians all work as a team to teach and care for patients. Nurse practitioners and pharmacists manage care much as a physician specialist would. Bouldin and the other physicians manage medical problems beyond the scope of the other professionals and supervise quality assurance. Bouldin acts as consultant to the physician directors in remote clinics.

The sparing use of physician manpower is one of the keys to the system’s reliability in regions with a dearth of medical resources.
The clinics are cost effective, too. It costs about $250,000 to start up a clinic, but reimbursement from private insurance, Medicaid and Medicare make it self-sustaining.

Other agencies and organizations have made valiant attempts to improve the health of Delta residents since the late Sen. Bobby Kennedy toured the Delta during the 1960s and was shocked to find such a depth of poverty and human suffering in the world’s wealthiest country. Well-intentioned and well- funded programs have come and gone in the Delta, leaving conditions pretty much the same as they were when the programs began. But there is real and palpable hope that it will be different this time.

Bouldin thinks the key to success will be the degree of collaboration between agencies, institutions and local communities. The founding partners of the Delta Health Alliance include the Delta Council, Delta State University (DSU), Mississippi State University (MSU), Mississippi Valley State University (MVSU) and UMC. Just in the programs devoted to health delivery and outreach, the Alliance funds the Delta Diabetes Project managed by DSU, along with a program to remedy the nursing shortage in the Delta; an outpatient electronic health record for Delta physicians; a rural tele-emergency program of the Mississippi Hospital Association; and a program of public health education by MVSU. Other project partners include Jackson State University, Capps Center for Workforce Technology, Mississippi Association of Community Health Centers, Mississippi Delta Area Health Education Centers, Mississippi State Medical Association, Primary Health Care Providers Association, and University of Southern Mississippi.     

Others are more inclined to give Bouldin the credit. Bill Triplett of the DRA, said, “We all know that Marshall Bouldin could be anywhere in the world that he wants to be, but he chooses to stay here. He tells the Delta, ‘it doesn’t have to be this way.’ He gives them hope.”



June 2007

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