Dear Madison County Health Department:

Pam & Beth – I have learned so much from the two of you this semester. About what a public health nurse does; about what public health nurses do far beyond their hours, job descriptions and salaries; about health concerns in Madison County; about the extent to which public health nursing reaches beyond seeing a client for a few minutes in an exam room – far beyond.

Thank you both for welcoming me at Cabbage Patch every Monday night and at every monthly meeting of the teen pregnancy prevention coalition. Thank you for introducing me to the participants of Cabbage Patch, making it so much easier for me to conduct my interviews.

Thanks for always making time for me, getting back to me (and so quickly) by phone and by email to answer my every little question. You were tireless sources of information, always patient, generous and kind, the way we hope nurses will be.

Holly, thank you as well for always getting back to me by phone and email to answer my every little question. Thanks for patiently interpreting data for me in a way that I could understand it, interpret it for others, and hopefully interpret it better on my own in the future.

Sonya, thanks for calling me back during what I imagined to be your only minutes of free time during the week – while driving to your 2nd job early on a Saturday morning! Thanks for sharing with me your passion for public health that motivates you to work so much.

Wanda, thank you for speaking so candidly with me that afternoon at Teen Matters and thanks for the tour of the clinic. You gave me very useful insight into the teen pregnancy issue in Madison County.

Finally, though not a staff member at the health department, you are definitely an active part of the programs there, Melanie, thanks for finding a way to open up to me about a delicate subject matter while still protecting the girls that you help so much. You have given me so much of your time this year. You’ve been patient and generous. You’ve always responded to my questions and generously offered me contacts who might provide even more information.

Everyone, it has been a privilege to get to know and to see the impact you make in Madison County.

So, thank you!
Sonya

Dear Madison Co. Beat Reporter 2011:

Here are just a few tips for you off the top of my head.

•Go to the MART (Madison Area Resource Team) meeting, also known as the Family Connection meeting, the 4th Tuesday morning of each month at the county courthouse. Get the exact time at the cooperative extension. The MART meeting will give you tons of story ideas and lead you to tons of sources, as it is a roundtable discussion for leaders of a number of community services as well as people interested in them.

•Give teen pregnancy a rest for a semester. I covered this subject to death this semester, and my sources were so kind, generous, and patient, and I would love for them to get a break from UGA journalism students.

•Don’t be sad – there are tons of stories. One I wanted to do, but never did, was the impact lack of transportation makes on public health and the delivery of health care services. Something a lot of people may not even think of. There aren’t any sidewalks or public transportation in Madison County, but there are plenty of people without cars. And the nearest hospital is nearly 30 miles away in Athens. How does transportation affect the ability to make and keep a doctor’s appointment? The health departments don’t take appointments; all services are all walk-in all the time, and part of the reason for this is the population’s difficulty keeping appts due to transportation challenges. And how about a sidewalk’s impact on physical fitness? A recent study I read about health disparities among rural people highlighted the increased obesity, diabetes and cardiovascular disease in rural America. The study revealed, however, that rural people are no less motivated to stay in shape and eat well, but they are isolated by geography – and some by lack of transportation - so opportunities to exercise or buy nutritious foods are limited.

•On that note, find out about the stroke and heart attack prevention program at the health department. It provides real incentives for clients to lose weight, and it seems to be working.

•Quite a few active members of the community and at least a handful of public health professionals attend Jones Chapel United Methodist Church. The nurse mgr. at the health dept. has mentioned her ability to serve the needs of the community not only through the health dept. but also through her church, and I’ve heard the pastor here has been a supporter of some of the projects of the health department. If you’re so inclined, attend a service here to get to know your community.

I’m sure I’ll think of more for you. And if you have any questions for me, feel free to contact me. Good luck! This is a great assignment! Have fun!
Sonya

Not a puff piece

I’ve learned a thing or two about writing in my life, and I know that words like “so,” “very,” and “really” are pretty much off-limits. I know that whether it’s a creative writing workshop or a journalism class, nobody really (oops) wants to read a piece about how wonderful someone or something is. In a poetry or fiction work, it’s drivel. In journalism, it’s a puff piece.

“Where’s the tension?,” “Where’s the conflict?,” would read the comments scrawled across my manuscript were I to write a story about nice people doing nice things.

So I feel that – although I’ve used my reporting this semester in stories for Professor Thomas’s class, Dr. Hume’s class, and the GA Public Health News Bureau – I haven’t had the opportunity to say what I think about the people I’ve encountered this semester, i.e. how so really very wonderful they are. So in this blog post, I’d like to take the opportunity to throw all good writing conventions out the window and speak freely. You've been warned.

Covering Madison County for this class and reporting for the GA Public Health News Bureau, I have interviewed public health nurses, doctors, emergency preparedness specialists, environmental health specialists, and nursing and public health professors (and I’m probably leaving some other professions out), and in doing so, I have met some people so dedicated to the well-being of their community, of the public, and of many people who do not have the means – or do not know they have the means – to be dedicated to their own well-being.

When I first went to the health department in Madison County, I admit, I expected to meet burned out, jaded state employees (and they have good reason to be – making at least $20k less than those who work in private hospitals and constantly absorbing the effects of seemingly endless cuts to state spending on public health). I believe I have probably met (in person or by phone) about 50 public health workers this semester, but I have not met a jaded or burned-out one yet.

When I first met Beth Heath – Madison County nurse manager and tireless source for many of my stories! – I thought she was special. I still think she is special, but I thought her willingness to work for very little just so she could be a public health nurse at a county health department was unique. Special it is, but since meeting Beth, I have met doctors, nurses, dentists, and environmental inspectors who work two jobs rather than give up public health in order to work a more lucrative job full-time.

Beth, however, does seem to embody the community spirit of public health. She took not one but two pay cuts in order to serve her community in the way she feels a public health nurse should. When Beth finished nursing school, she “had to” take a high-paying job as a pulmonary nurse at Athens Regional because, though she really wanted to work in public health, health departments at the time didn’t hire new grads. So she bided her time at ARHC until an entry-level job opened up in Jackson Co. She worked there a few years and even got promoted, but when an entry-level job opened up in Madison Co., she took it and another pay-cut. Beth believes that the community is best served by a public health nurse that lives in that community, so she applied for the demotion in order to work in the county where she lived. Sure, working close to home must have had personal advantages for Beth, but it seems to me that she wouldn't take another pay-cut just to shorten her commute by a few minutes. She had greater benefits in mind.

And it’s not just the sacrifices these folks make, it’s the modesty! In my first interview with Beth, I said, “So you took a pay cut when you left Athens Regional?” And she said, “Yeah, but everybody takes a pay cut who works in public health.”

When a dentist at the Chatham Co. health dept. mentioned that he worked a second job, I didn’t mask my admiration, and he said (with a shrug in his voice), “I don’t know anybody in public health that doesn’t work two jobs.”

Sonya Willard is one of them. She’s a nurse in Madison County, and in her “free time” she’s going for a higher nursing degree and in the remaining “free time,” she moonlights at a hospital. When I asked her why she didn’t just work in a hospital full-time – where she could easily double her salary at the least – she said she loved working at the health department too much.

Karen Palmer is an area nurse manager in the Gainesville district, and she said that when she gets a check from her weekend hospital job, she has to remind herself why she stays in public health, but that one of the reasons she stays at the health department is the opportunity it gives her to empower women to learn about and take care of their bodies.

Most people I interviewed said the health departments gave them opportunities private hospitals did not to really care for patients comprehensively, which means taking care of the whole person – not an acute issue – on a long-term basis with plenty of follow-up.

It’s not just nurses. Dr. Lynne Feldman, director of Valdosta’s Southwest district works two jobs, too. Imagine that – a doctor working two jobs. She said, “Salary and benefits are always an issue, but whether or not you like the work is also an issue.” I wish more people felt that way. (Personally I have always thought enjoying what you do is more important than the pay – yes, I know this attitude is a luxury that many can’t afford – but I know a lot of people who would think my attitude absurd.)

Another dentist – few health departments have dental programs, and the existing ones are really hanging on by (may I make a bad pun?) the skin of their teeth – took a voluntary 20% pay-cut in order to prevent his county’s dental program from being retrenched, and his hygienist voluntarily gave of 10% of her pay.

A public health authority who I interviewed asked not to be quoted on the following, and I will gladly acquiesce because it’s clearly not true. He said, “Those who work for state and county public health are either very dedicated or they can’t get a job anywhere else.”

Clearly, they can all get jobs anywhere else, and they all do! So he was right on one count: public health professionals are really, so, very dedicated.

-Sonya Collins

NOTES:
*I would like to apologize to every teacher, student, editor and peer-editor I’ve ever had for using so many “writing profanities” in this post.

*I’d like to acknowledge that there are many, many more people who sacrifice for public health and the health departments. I have met only a few of them and mentioned far fewer. Just a couple others are Wanda Strickland, Pam Smith, a whole crew of people in the Coastal, North, Northwest, West Central, South and Clayton Districts, i.e. they’re spread across our entire state. And since I’ve abandoned all efforts to avoid cliché and other undesirable writing conventions, I’ll sign off with this: If you meet someone who works in public health in any capacity whatsoever, please tell them thank you.

Nothing to do today? Or nothing to do tomorrow?

I’ve been talking to Madisonians about teen pregnancy since January, and no matter whom I interview – teen mom, nurse, epidemiologist, counselor, parent, advocate – I always ask the question, “Why is the teen pregnancy rate so high in Madison County?”

Those who don’t work in healthcare or social services all shrug and say, “I guess because there’s nothing to do.” But I couldn’t accept that answer. There’s nothing to do in suburbs all across America. What makes Madison County different?

Poverty, of course, sets Madison County apart from the suburbs. But what does poverty have to do with pregnancy?

When I first met Melanie, she also said that it must be because there’s nothing to do. Melanie was a teen mother herself, and the daughter she bore at age 17 went on to become a teen mother. In addition to running a teen parents support group at Madison Co. High School, Melanie’s a member of the Teen Pregnancy Prevention Coalition, and she’s an active advocate for teen pregnancy prevention in this small community. So I thought she was going to give me more than “there’s nothing to do.” I expected her to have the answer. Nothing to do may explain teenagers having sex, but it doesn’t explain so many of them getting pregnant.

Because Melanie is a major player on my teen pregnancy beat, I’ve run into her many times this semester. Last week we sat down for an official interview. We met in the conference room at the health department before the March Coalition meeting and as the meeting was just getting started, she said to me, “Sometimes I feel like a double agent. I’m supporting the teen parents one day at my support group, and I’m over here trying to prevent teen pregnancy the next.”

I said, “But aren’t you trying to prevent more teens from needing support?”

She said, “Sure, but I wonder if the girls would think I was betraying them. Sometimes I think they don’t even think teen pregnancy is a problem.”

Now we were getting somewhere. It’s not that there’s nothing to do. If girls don’t think there’s anything wrong with having children before they finish high school (yes, children, I’ve now spoken to or heard of many who had 2nd and 3rd children before they were 18; I’ve learned that it’s not just a battle to try to keep girls from getting pregnant in the first place, but it’s just as hard to try to keep them from getting pregnant again), then why would they go out of their way to prevent it?

A couple of days later, I met with Wanda Strickland (pictured above), the nurse at the Teen Matters Clinic.

I asked her, “Is this [the clinic where we were sitting] where girls find out they are pregnant?”

“Yes.”

“What is that moment like?”

I was ready for her to tell me about the tears and the terror in their eyes.

“A lot of them are happy. A lot of teenagers want to be pregnant,” she said.

I was stunned silent for a minute – mainly because the following questions I had pre-written were based on the answer I expected to my last question but didn’t get. Now I could only ask, “Why?”

“It’s generational poverty. If you have no goals and your parents have no goals, you set up a whole different standard of norms. For some people the goal is just to survive, to get the rent paid for the week.

“So I ask every kid who comes in here, ‘What grade are you in? Where are you going to college? What’s your goal? Because for some of them, nobody has ever asked them that.”

ACC.10

Taking a brief break from my self-assigned pregnancy beat, I attended one day of ACC.10 – the 59th session of the American College of Cardiologists in Atlanta yesterday. A couple of story ideas came from it.

There were three posters that I’d like to find a way to work into one story and (but how?) relate to Madison Co.

• “Government-Sponsored Health Insurance and Lack of Insurance Are Associated with Adverse Cardiac Effects.”

• “Money Left Over at the End of the Month and Outcomes After Myocardial Infarction.”

• “Medical Cost Burden and Outcomes After Acute Myocardial Infarction.”

All three support the theory of Unnatural Causes: financial stress has an adverse effect on your health.

I’m not sure what the news article would be here. Just to say that these studies were done and what the result was? Is that enough? How to relate to Madison Co.? Sure, I know the people who care for the financially stressed in Madison County, but what to ask them?

The other story ideas came from the session on the Hospital to Home initiative (H2H). 25% of patients with cardiovascular disease are readmitted to the hospital within 30 days of discharge, and H2H’s mission is to reduce this rate by 20% with the collaboration of hospitals across the country.

I’m interested in two aspects of this initiative:

Community Collaboration: The focus of H2H is on improving the transition from hospital to home through follow-up home visits, phone calls, education, overseeing of meds, etc., and the creators of the initiative emphasize the importance of the community, such as pharmacists and community organizations, in helping carry out its mission.

This was interesting to me because I recently spoke with Gary Rost, executive director of Savannah Business Group on Health (SBG), who has been working on the development of a coastal Georgia health coalition for the past few years. Rost believes that no single health organization – such as public health – can possibly respond to the health needs of all the people. He believes the health coalition concept (or strategic partnerships, as H2H calls it) is “absolutely” the answer. Both SBG and H2H hold that the health of the community is the responsibility of the whole community.

Dr. Zsolt Koppanyi, director of the West Central health district (Columbus, GA), said that even though public health has beautiful plans in place for all types of situations, there simply aren’t enough people to carry out these plans. Finally, I spoke last week with Kevin Caspery, an MPH who works for a private firm that does consulting for the CDC. He commended the CDC for its reaching out to so many branches of the community in order to create strategies; he also seemed to feel that this is the way to respond to health needs.

So my story idea is the community health coalition as a possible solution to a public health system that has no money and is severely understaffed.

Transportation and Health: One way H2H wants to improve the transition home is through scheduling follow-up appointments for dates sooner after discharge and making sure the patient actually has a way to get there. The speakers in this session said that too often follow-up appointments are not kept and, when scheduling the appointments, healthcare providers don’t ask the patient how he/she will get there.

This reminded me of Madison County. In my first meeting at the cooperative extension, Debbie Phillips told me that lack of transportation is too often a barrier to the poor getting care and services that they need. County nurse manager Beth Heath has also mentioned lack of transportation as a significant barrier to getting proper care. This is compounded in Madison County by lack of any public transportation – or even a sidewalk for that matter – no hospitals and only a private ambulance service. We don’t always think that whether or not one owns a car could impact one’s health.

Maybe this is a story idea?

First Cabbage Patch Class

Monday, February 8, 2010

I’ve started to cover the pregnancy beat in Madison County, which – as far as social services are concerned – means the teen pregnancy beat because, according to Beth Heath (Co. Nurse Mgr.), most of the moms they serve are teens.

Tonight I went to my first Cabbage Patch class, a program that Beth started when she was in Jackson Co. and that she replicated in Madison Co. (There's Beth above, signing the attendance sheet for one of the moms-to-be.)

Cabbage Patch is a weekly class for expectant mothers (and their partners and families) that runs nine weeks. While it isn’t expressly designed for teens, the majority of the group is teen-aged (some are very young teenagers) and the remainder is 20-21 years old.

Each class is on a different topic, such as nutrition, newborn care, and delivery. There are pre-tests and post-tests on the topic at the beginning and end of each lesson from which the district’s epidemiologist collects data on the outcomes of the class.

Since the program has begun, Madison County has seen reductions in preterm labor, low birth weight and prenatal smoking, and increases in birth control use, spacing of pregnancies, and initiation and duration of breastfeeding.

The program itself is a portrait of the ways in which public health is overworked and under-resourced. First of all because there is statistical evidence of the value of this preventive program, but the state still does not have money to invest in it.

When Beth started the program, with then-county nurse manager Pam Smith, who is now the District Nurse, there was no public health funding for prenatal classes, so if they wanted to proceed, they would need to find grant money on their own. They were finalists for a March of Dimes grant though they did not get it. And they were recipients of a Jackson EMC Operation Roundup grant for two years, and they were able to stretch the money over three years.

The current session of Cabbage Patch ends March 22, and it will only run again if the clinic gets another grant.

Pam or Beth teaches most of the lessons, and a few are covered by other specialists, such as a certified breastfeeding peer counselor. The grant money, then, is needed for incentives. Each week, every expectant mother gets some really nice swag for attending the class, such as a Moby Wrap, the famous What to Expect When You’re Expecting, ear thermometers, bath thermometers, and – following their nutrition lesson – a gift card for a local supermarket with which they are challenged to buy healthy foods that they wouldn’t normally buy. But the pièce de résistance, and certainly a major stimulus for most students’ perfect attendance, is the new car seat they receive on the last night.

The final lesson is two hours long and given by a certified car seat technician who properly installs the seat in each expectant mother’s car.

Each county clinic is required to stay open late one night per week, so Cabbage Patch classes are held on their late clinic night when Beth would be there anyway. But Pam is there on her own time. And both she and Beth, as well as other members of the clinic staff, regularly and voluntarily stay past 7 because of this class. And they make runs to Wal-Mart for the incentives and research and write grants often on their own time as well. As Pam said, “Beth and I both live in Madison County, so the way we see it is that we’re just doing something for the community.”

Sigh.

When I asked Dean Phillip Williams of the College of Public Health why anyone would go to work for the state or at county clinics when they can get so much more money working for federal agencies or in the private sector, he said, “They are just very dedicated.”

I’ll say.

More to come about the moms-to-be at Cabbage Patch.

Family Connection Meeting

Tuesday, January 26, 2010

As soon as I tell anyone what I am doing in Madison County, they respond – without pause – “Teen pregnancy. That’s the health issue in Madison County.”

It was first mentioned to me in a meeting at the cooperative extension with Leigh Anne Aaron, county extension agent, and Debbie Phillips, county program coordinator.

I admit, my first thought was, Yeah, yeah, sure. What else have you got? To my mind, it was a retro-topic. The stuff of after-school specials. I wanted something sexier.

About a week later, I went to the Family Connection meeting at the chamber of commerce (see image) – a monthly summit of the representatives of a handful of county resources. Around a large conference table sat the county nurse manager; a representative from a community garden organization; the coach of a baseball team for children with special needs and the mother of a player; a parent representative of PRIDE, a safe driving program for teens; and, finally, a parent representative from the Teen Pregnancy Prevention Coalition and, announced in absentia due to the flu, Melanie Berryman, the leader of Madison County High School’s Teen Parent Support Group. Of the handful of focused issues represented at the meeting, teen pregnancy was the only one that was repeated.

I had come to this meeting to find another story idea. Then, as if I hadn’t eaten my vegetables the night before, here they were waiting for me at the breakfast table.

Teen pregnancy was not what I thought I’d be writing about, but now it seemed wrong not to. I knew I wanted to write about the health concerns that mattered most in this county. Who was I to decide which issues were “cool enough to matter”?

The media have the power to make health issues seem to disappear when they are no longer in fashion. But what if journalists continued to cover an issue as long as it continued to be an issue – covering the story until it disappeared, rather than forcibly making it disappear?

First Visit to Cooperative Extension

Friday, January 15, 2010

After meeting with Leigh Anne Aaron and Debbie Phillips at the cooperative extension in Danielsville, I understood Professor Thomas’s mantra “Every story is a health story.”

The poverty rate in Madison County is in line with national averages, which are 13-17% at any given time. But when Leigh Anne looked up the rate for me in the 2009 Georgia County Guide, Debbie said “Is that all?” They must see a lot of poverty. Over the next hour and a half, Leigh Anne and Debbie shared with me the struggles of the rural poor that they have witnessed through their work at the cooperative extension.

I saw that every story about the poor is a health story because being poor means doing without and what the poor do without is some of the basic necessities of good health. And they aren’t the necessities of good health that I might have thought of right away, like health insurance. It’s not just lack of money; it’s lack of intangible things, mainly information, which have a major impact on health. And they lack access to tangible things as well. In Madison County, those tangible things are hospitals, public transportation and sidewalks. So being a car-less resident of Madison Co. might make getting to a doctor’s appointment simply impossible. This may lead to not seeking medical care at all, and the cycle goes on and on.

Beth Heath, the county nurse manager, told me that while clients can see a nurse for free at the health department, if they need a doctor, the nearest free doctor is at Mercy Clinic in Athens. All the doctors there are volunteers and wait times for an appointment average about two weeks. The wait time combined with the hurdle of transportation makes it likely that health department clients will just leave their problems untreated if they can’t be resolved by a nurse.

This cycle is compounded by the fact that some of the poor of Madison Co. are forced to choose between resources that could help them improve their situation and social services that they need urgently. Debbie said that some social services in the area use cell phone ownership and Internet subscriptions as indicators of someone’s not being “poor enough” to get assistance.

A number of programs available to the needy in Madison County illuminate specific needs of the residents and also story ideas.

Leigh Anne holds a grant position for energy education. She educates natural gas consumers on ways to save money and on resources available for assistance in paying heating bills. She says people lose their heat every year – many of whom were unaware of resources or protective laws. Leigh Anne has visited homes heated by conventional ovens or camp stoves, i.e. an open flame burning atop a tank of gas. The Obama administration announced in January that it is releasing $50 billion dollars in federal money to LIHEAP (Low-Income Home Energy Assistance Program), $19 million of which has been allocated to the state of GA.

Teenage pregnancy is also an issue in the county. Teen mothers are so prevalent in the county that a support group meets after school at the high school. Some participants are pregnant; others are already mothers. The group is run by a volunteer – a Jackson EMC employee – who was a teen mother herself. She brings in speakers (doctors, nurses, health educators) to educate the girls on nutrition, pre-natal care, breast feeding, etc. Nancy Bridges, the cooperative extension’s family and consumer services agent for Madison Co., has given nutrition workshops for this group.

The county has just gotten a Teen Matters Clinic. Its presence illustrates the need for sexual education for teens, reproductive healthcare and access to contraceptives.

The health department also runs the Teen Pregnancy Prevention Coalition, a program that trains parents to hosts “parties” for other parents of teens, and at these parties, the host teaches the guests effective ways to teach their children about pregnancy prevention within the framework of their own beliefs and values, be they Christian-based abstinence or something else.

Finally, hunger is an issue in Madison Co., and this is apparent in the presence of several charitable programs that get food to the needy, such as Angel Food Ministries (monthly in Madison) and the USDA’s quarterly commodities drop-off. I’d like to go to a commodities drop-off if one falls during this semester – if not an Angel Food Ministries pick-up – and report on the people who use these services. I’d like to put a real face on hunger in our area. I think hunger is too often associated only with people in very far away places, and I think a story about who is hungry in our area (and why) would be illuminating.

I recognize that an obstacle to all of my story ideas is that I would like to meet people who may feel some shame about their situations: the poor who cannot pay for their heat, the hungry, and teen mothers. I’ll get a lot of practice on this beat in gaining the trust of my sources.

First Drive to Madison County

Friday, January 15, 2010

Heading north on 29 out of Clarke County towards Danielsville, I watched the landscape clearing to my left and my right. The intervals between buildings grew larger and the buildings smaller. The landscape changed from comparatively urban to rural. And I literally sighed with pleasure. A flea market in a dilapidated metal building with a hand-painted sign that reads GRAND OPENING; tiny houses, their paint chipping, set far from the road; the simple life.

Then I remembered Australian journalist Suzanne Clarke’s A House in Fez and her attitude towards poverty in Morocco. In one scene, she goes to Marrakesh after not having seen it for four years, and she is disappointed that a city square that was once packed with peddlers at makeshift carts and “food stalls that were wheeled out every night, once helter-skelter, had been tidied up. They were now in neat rows […], numbered and lit up, their menus displayed on boards […] Where was the glorious panoply of culinary choice in a charmingly rundown setting that had once existed? I was dismayed to see a modern, fluorescent-lit boutique between the stalls.”

Charmingly rundown? Had she wanted the people of Marrakesh to live “helter-skelter” lives forever so that she could maintain her romantic view of poverty? So that she could be “charmed” by their “rundown” world every time she decided to spend a weekend away from Fez, where she was pouring money into the house she was renovating there? It seemed to meet that felt Marrakesh was a theme park. But it was someone’s reality, whether or not it was hers. She was “dismayed” that in the four years since she’d been gone, the peddlers of Marrakesh had been able to bring something “modern” – if only fluorescent light – into their lives? That they’d been able to “tidy up” and organize themselves into businessmen and women in the hopes of bettering their lives?

It was just like many tourists I'd seen when I was living in Brazil who’d shoot picture after picture of the favelas (slums) and call them “amazing.” Well, I’m glad you like them! Glad you could come down to Brazil and see something so beautiful as human suffering! Brazilians have a word for this. They say that tourists love the pobreleza (pobreza [poverty] + beleza [beauty]). It upset me to see people so charmed by misfortune.

And now I had just sighed at what might be “quaint” indicators of poverty myself. Wasn’t “the simple life” just a phrase coined by people who could choose that life – whether for vacations or permanently? For some people rural life is not simple at all, precisely because it is rural. For many, the rural landscape – void of hospitals, even sidewalks in Madison Co. – can make life pretty complicated.