Guinea Worm

Around this time last year, I was taking a class called “Health Care Issues: Global Perspectives” at UT Dallas. This is the class that really cemented my desire to pursue a master degree in public health. We spent time learning about different cultures and their health care systems, health issues, and experiences with western medicine with a large emphasis on cultural competency. One of these lessons focused on the affect socioeconomic status has on health. The Guinea Worm is an easily treatable-and preventable, parasite that affects families in poverty in Africa. The parasite made headlines again this week as the efforts to eradicate the disease continue.

The Guinea Worm parasite, Dracunculus medinensis, is spread through infected water sources, such as pools, ponds, and standing water, in Africa. A person infected with guinea worm grows the parasite in their digestive tract or body cavity until the parasitic worm is approximately 2-3 feet long. At this time, the worm is ready to emerge. A blister forms on the legs and feet, creating a painful burning sensation until it emerges, which can take days to weeks. To relieve pain, infected persons often submerge their foot in water (such as in a lake or stream). Thus, the parasite is exposed to it’s ideal element, water. This encourages the worm to emerge bit by bit, where it releases millions of larvae into the water. This is often the same water that the other members of the community use to drink or bathe in, allowing the parasitic larvae to find a new host. Thus, the infectious cycle continues.

Although the infection is not deadly, it is disabling and debilitating for those infected. Given that the disease is concentrated among poor populations, the additional disability prevents family members from working or contributing to the familial needs, deepening poverty and limiting resources. A 1989 study titled Guinea Worm: An in Depth Study of What Happens to Mothers, Families, and Communities(though dated) accurately depicts the struggles that families often deal with in the face of widespread infections and their desire to eradicate the disease from their community. The parasite has no vaccine or adequate treatment. The most effective way to combat infection is to prevent it altogether. To prevent the spread of the disease, infected persons should not be in or near community water sources. Some of the countries battling these parasites have enacted laws that do just that- prevent infected people from spreading it to others. Some areas have even employed guards at water sources. The most important facet of this disease is that the parasitic infection can easily be prevented with a simple cloth filter, pipe filter, or by establishing a safe, covered water source. Thus, even communities without a water pump or a system of water purification can filter water to prevent infections. This solution is accessible to members of even the most destitute communities.

Eradication of this disease has been the goal since the 1980’s. If the disease were to be globally eradicated, it would be the first parasite and only the second human infection to be eradicated in history (second only to smallpox). The Carter Center is former President Jimmy Carter’s brain child, and it has been one of the driving forces behind the efforts for the past 30 years. It has worked alongside the CDC, WHO and UNICEF towards eradication. Their work has not been without reward. According to the Carter Center website, “In 1986, the disease afflicted an estimated 3.5 million people a year in 21 countries in Africa and Asia.” This is compared to 2017’s reported 30 cases- more than a 99% reduction in the disease. Eradication efforts have focused on education, political change, and providing safe drinking sources to members of communities affected by infection.

According to CNN, South Sudan became the latest country to announce a victory against the “fiery serpent,” stating that they have not had a case reported for the past 15 months, a major milestone in the path towards eradication, especially considering that this accomplishment comes in the midst of a raging civil war that has been ongoing since 2013.

Want to see what the Guinea Worm infection is like? The New York Times has a great (somewhat grotesque) video titled “The Guinea Worm Slayer” that can be viewed here. A word to the wise, this video may not be appropriate for squeamish souls- or if you are planning on having spaghetti for dinner.


The Opioid Crisis

The public’s awareness of the seriousness of the opioid epidemic has been growing since the presidential election in 2016. The conversation continued to grow after Dr. Jerome M Adams was appointed the new Surgeon General. Then in October, President Trump declared the opioid epidemic a public health emergency.The discussion continues to grow as government officials, organized bodies, and members of our community call for change and awareness of the epidemic affecting Americans all over the country.

The NY Times states that “drug overdoses are the leading cause of death for Americans under 50.” In fact, there were 63,000 drug overdose deaths in 2016. According to the Washington Post, there were “174 deaths from drug overdoses every day in 2016, one every 8½ minutes.” Of these, approximately 115 deaths are from opioids. This is simply the tip of the iceberg. There are opioid users and abusers throughout the country, taking prescribed or recreational opioid medications. An estimated 11.5 million people have misused an opioid prescription and these numbers continue to rise.

What is an opioid? Opioids are a type of narcotic, a chemical pain reliever. These chemicals bind to receptors in the brain and spinal cord, blocking pain signals. It can also create a feeling or euphoria, known as a “high.” The first opioid was derived from a plant called opium. Originally this plant was found in the eastern Mediterranean. Now, the opium poppy grows throughout Asia and the Central and South Americas. Now, there are a multitude of medications in this category called opiates. Current medications in the opioid family are morphine, hydrocodone, oxycodone, heroin, codeine, and fentanyl. These medications are also known by their name brands, ie: Percocet, Vicodin, Oxycontin, etc. While drugs like morphine and codeine are found naturally in opium, drugs like hydrocodone and oxycodone are semi-synthesized and drugs like Fentanyl are entirely synthetic pain relievers.

How did this epidemic start? The Department of Health and Human Services offers a general time line of the emergence of the epidemic. Presumably, the epidemic began in the 1990s as physicians began prescribing more and more opioid medications that were (at the time) believed to be safe and non addictive. With the prescription of any medication, there is always the risk of misuse, whether accidental or intentional. In fact, misuse of prescription medication is second only to marijuana use as America’s choice of illicit drug use. So, naturally with prescription opioids, as the number of prescriptions increased, so did the frequency of medication misuse. Then, it became clear that these medications were addictive. Misuse of prescription medication occurs because there is a common misperception that prescribed drugs are less risky than illegal substances because they are controlled by regulating bodies. This is simply not true. Here are the statistics. Roughly 21- 29% patients taking opioids for chronic pain misuse them. The most common reason for drug misuse (using a drug at a higher dose or frequency as prescribed or without a prescription) is for pain relief. The second most common reason is to get “high.” A portion of those develop an opioid use disorder and some transition to the illegal drug, heroin. In fact, a majority of heroin users started their drug use first with a prescription medication. (Does the term “gateway drug” ring a bell?) The New York Times reports that the current epidemic is now no longer just about prescription medications. Instead, the crisis has taking a turn to illegal and non-prescribed medications like Fentanyl, which has been a major player in turning the crisis into an outright epidemic.</p


What are we doing about this? There have been actions taken to control the growing epidemic over the past century, and efforts have increased as the epidemic has worsened. However, until recently, it appears that too little was done, too late. In 2007, federal government brought criminal charges against Purdue Pharma for their misleading advertisements about Oxycontin. More recently, Alabama has brought similar charges against the pharmaceutical production company. The Department of Health and Human Services has outlined a 5 step plan.
1.Better addiction prevention, treatment and recovery services
2.Better targeting of overdose reversing drugs
3.Better data
4.Better pain management
5.Better research

The National Institute of Health is also involved in the fight against the opioid epidemic. Their plan is also listed below:
1.safe, effective, non-addictive strategies to manage chronic pain
2.new, innovative medications and technologies to treat opioid use disorders
3.improved overdose prevention and reversal interventions to save lives and support recovery

Nongovernmental companies are also starting to step up. CVS has put new regulations on their manner of dispensing opioid prescriptions for certain conditions. Other organizations have also stepped up. The American Society of Addiction Medicine has formed the Coalition to Stop Opioid Overdose and Advocates for Opioid Recovery has formed to help drug abusers beat their addiction.The momentum for resources and solutions in the midst of this crisis continues to grow. As of 2018, there has been more funding funneled into treatment and law enforcement as well as the development of a Prescription Interdiction & Litigation Task Force.

If you are interested in more information about the opioid crisis, the CDC provides a plethora of information regarding the use and abuse of opioids in the USA.


Is There Something Fishy About Fish Oil?

Fish intake has been encouraged by nutritionists and physicians for years. Fish are a component of a healthy diet and have been linked to a multitude of health benefits. Fish oil as a supplement has long been touted as a home remedy cure-all (much like coconut oil in recent years). Mother’s used to give cod oil by the spoonful and now there are a variety of pills available on the market. In fact, the NIH states that fish oil supplements are the most common nonvitamin supplement taken in the USA. So does fish oil really work? The answer is unclear.

What makes fish oil so important? Well, our bodies need carbohydrates, proteins and fats to develop and function properly. Some of these elements we can synthesize ourselves but others can’t be made by our bodies. These essential elements have to be obtained from our diet. Fish oil is high in omega-3 fatty acids, mostly DHA and EPA. While these particular omega-3s are not essential (unlike ALA which is found in plant based food), they are difficult to synthesize and it is currently the recommendation that we obtain these fats from our diet. A Harvard blog explains that “omega-3 fatty acids play important roles in brain function, normal growth and development, and inflammation. Deficiencies have been linked to a variety of health problems, including cardiovascular disease, some cancers, mood disorders, [and] arthritis.” So, even though these fatty acids can be made by our bodies, the best dietary source is through fatty fish, such as salmon, sardines, lake trout, albacore tuna, herring, and mackerel. Over the years, as dietary supplementation has grown in popularity, fish oil supplements have gained traction. The concept is that you can reap the benefits of omega-3 fatty acids through pills and by-pass the fishy meals altogether. The question is, does it really work?

An article posted by CNN brings light to the fish oil debate. This discussion has been at the forefront among health experts for many years. In fact, fish oil has been used as a remedy for a myriad of ailments for centuries. Vikings used fish oils in from the 8th to 11th centuries. Europeans used fish oil in the 1700s. By the 1800s, countries around the world were producing and consuming fish oil and fish oil products. The CNN article notes that there is a growing interest in the affects of fish oil on our brains (which are large consumers of omega 3 fatty acids. It cits a 2010 study that revealed ” women who took the supplements during their pregnancy were just as likely to experience postpartum depression as those who didn’t and the brains of their babies didn’t appear to grow and develop more quickly than other babies.” Fish oil intake has also been linked to reduced ADHD intake, reduce brain aging, lower risk of heart disease, weight loss, and possibly increased brain recovery. In fact, Bobby Ghassemi and his family believe that the omega 3 fatty acids helped him recover from his traumatic brain injury.

The CNN article mentioned above sites a new study, aptly titled “Diet during pregnancy and infancy and risk of allergic or autoimmune disease: A systematic review and meta-analysis.” This study aimed to determine if there was a correlation between maternal diet during pregnancy and the development of allergic and autoimmune diseases in infants. For anyone keeping up with the studies relating to the correlation of food exposure and food allergies, such as the never ending debate about peanut exposure (such as this discussion in the NY Times), this study is along the same lines. However, it bypasses the “what age” question by going directly to age zero, fetal development. Babies are exposed to some components in the mother’s blood that can pass through the placental barrier to the fetus. Additionally, mother’s pass things along to their newborn babies through their breast milk. Thus, it makes sense that what mom is exposed to, the baby is exposed to. What she eats, the baby eats. The difference is that this study looked at these things systematically and tried to find a correlation to the infant’s health. The results are clear. The study clearly states, “maternal probiotic and fish oil supplementation may reduce risk of eczema and allergic sensitisation to food, respectively.” (As a side note, the study also put in its 2 cents about the peanut debate by stating “early peanut or egg introduction to the infant diet reduces risk of peanut or egg allergy.”)

On the other hand, it is important to note that not all findings regarding fish oil have been positive. High intake of oily fish has been linked to prostate cancer. Additionally, fish oil from actual fish in your diet, can possibly increase your mercury intake. The American Academy of Pediatrics notes that fish such as shark, mackerel, tuna and varieties of fresh water fish are more likely to contain mercury than other fish. Pregnant women and their babies are especially advised to limit their intake of these types of ocean dwellers. Additionally, fish oil supplements are not well regulated because they are not under the regulation of organizations like the FDA. Thus, the quality of the pills can vary greatly. Additionally, omega-3 fatty acids are relatively unstable molecules that are prone to oxidation. This breaks down the fatty acid chain into other types of fat molecules, essentially lessening the quality of the pills.

Lastly, all of these findings (positive or negative) may be most apparent among subsets of the population and many of these findings have inconsistent results. Additionally, the benefits of omega 3 fatty acids are often not well isolated from the benefits of increased fish intake in and of itself. Eating less red meat, consuming more lean fats, and the vitamins and minerals found in fish alongside these fatty acids may also contribute to positive outcomes, rather than just omega-3 intake alone. Many studies do not study isolated supplement intake or have too weak/inconsistent findings to offer definitive findings that are applicable to the general population. The best advice is vague but true. CNN states “Most health experts recommend that people try to eat a healthy, balanced diet to protect against diseases and most cancers, and turn to supplements only if that’s not possible, since supplements may provide only partial benefits.”


The Battle of Fluoride Against Cavities

Public drinking water in the United States has been treated with fluoride for 70 years. This is widely recognized by public health organizations as one of the top acheivements in public health over the past century. But, why is fluoride added to the water we drink? The idea is that fluoridated water prevents dental caries (cavities) and keeps teeth strong. Mulitple organizations, such as the American Dental Association, American Academy of Pediatrics, US Public Health Service, and World Health Organization promote fluoridation of water because cavities are still one of the most common diseases of childhood today.

What is fluoride? Fluoride consists of a group of compounds containing the element fluorine. It is a naturally occurring element found in water, air, rocks, and soil throughout the world. The benefits of fluoride in water were discovered in the 1940s when scientists noticed that populations that drink water containing naturally elevated levels of fluorine have less cavities. This is because fluoride reduces the growth and establishment of bacteria in the mouth, which can harm tooth enamel.

What are dental caries? Dental caries are most commonly called cavities. This is the break down of tooth enamel, which is the outermost, protective layer of the tooth. According to the CDC “This acid eats away minerals from the tooth’s surface, making the tooth weaker and increasing the chance of developing cavities.” Severe and untreated cavities can cause further infection, such as cellulitis and require hospitalization for adequate treatment. The prevalence of dental caries is so large that the NIH actually tracts statistics regarding the prevalence and severity by age group! Images of dental caries can be found through the California Dental Association

What are the risks for fluoridated water? The first risk most people associate with fluoride is the possibility of toxicity. The ingestion of a high level of any element can have adverse effects on a person’s health. According to a study titled Fluoride Toxicity, toxic levels of fluoride can “provoke chronic joints-pain, ligaments-calcification, osteosclerosis.” The list extensively lists complications with bone structure/function and alterations to te levels of other minerals in the body. At very high levels, there are even neurological risks. The American Dental Association website has multiple resources regarding evidence that fails to support a correlation between fluoridated water and neurological consequences such as lowered IQs. However, it appears that the most common risk is dental fluorosis. This is damage to the enamel of developing teeth in children before the tooth breaks through the gums. For most people affected by this condition, the effect is largely cosmetic and does not have negative health outcomes.

What can be done to reduce your toxicity risk? First off, the amount of fluoride in our water is relatively low compared to the minimum toxicity level. Potential fluoride toxicity from oral medicaments: A review notes that “the minimum optimal dose likely to cause toxicity and requiring therapeutic intervention has been set at 5 mg/kg of body weight.” this is well below the current level of fluoride in water which is 0.7 to 1.2 ppm. For those of you concerned for dental fluorosis, Newsweek notes that the levels of fluoride in our water have been decreasing nationally since 2015.

The National Cancer Institute notes that a study in 1990 showed a link between osteosarcomas (bone cancers) in rats given water containing high fluoride levels over a prolonged period of time. However, it is important to note that the results of this study have yet to be replicated, even through a meta analysis of 50 human subject studies. Further studies and reviews evaluating the link between fluoridated water and bone cancer over the past 40 years have yet to create any sort of correlation between the two.

Why don’t we just use fluoridated toothpaste? While fluoride is found in many dental hygiene products such as toothpaste, mouth rinses, and dietary supplements, it can also be found in your diet. Foods such as fruits, vegetables, chicken, infant cereals, ready to drink juices, and canned goods contain some levels of fluoride. Livestrong recommends things such as tea and baked potatoes as sources of this mineral. So, why is fluoride still added to our drinking water? Fluorinated water is the most cost effective means to ensure that the public maintains optimal fluoride levels to maintain healthy teeth. Additionally, although there are other fluoride supplements available to the public, studies still show that communities that drink fluoridated water still have a up to 35% less cavities in their children than communities that do not drink fluoridated water.

So, cheers to some sparkling water and healthy teeth! Drink up!

Famous Names · Uncategorized

Dr. Elizabeth Blackwell

A tribute to my recent acceptance to medical school, this month’s Famous Names in Public Health series post centers around women’s achievements in medicine. This notable figure was the first woman to earn a medical doctorate degree in the United States. Her name is Dr. Elizabeth Blackwell.

Dr. Blackwell was born in 1821 in Bristol, England. Her family immigrated to America in 1832 and settled in Cincinnati, Ohio. Here, her father and family became advocates for the abolition of slavery and for the establishment of women’s rights. After her father passed away in 1838, her mother, sisters and herself became teachers as a means to support themselves and their family. According to Changing the Face of Medicine, Dr.Blackwell first turned to medicine because “a close friend who was dying suggested she would have been spared her worst suffering if her physician had been a woman.”

Dr. Blackwell consulted her family’s physician friends for advice and studied medicine under the guidance of 2 of these physicians for 1 year before applying to multiple medical schools on the east coast. Many schools at that time would not even entertain her application because their programs were not available to women. One school however did consider the idea- Geneva Medical College. Apparently, the faculty allowed the students (who were, of course, all male) vote on her admission because they thought it would never go through. However, the student body jokingly voted to grant her admission to the school. (It’s pretty shocking how a practical joke ultimately led to a change in history!) She graduated from the program in 1849 with her MD degree. She was the first in her class, gaining respect from faculty and classmates alike.

From there, Dr.Blackwell practiced medicine in London and Paris until 1851. When she returned to New York to practice medicine, she struggled with discrimination and had difficulty finding work. Neither hospitals were willing to hire her, nor patients willing to see her. Even a women’s department was unwilling to hire her as a practicing female physician. As a result, Dr. Blackwell opened her own small clinic in the city to treat women. In 1857, Dr. Elizabeth Blackwell, her sister; Dr. Emily Blackwell, Dr. Marie Zakrzewska, opened the New York Infirmary for Women and Children. In 1859 she became the first woman to have her name entered in the British General Medical Council’s register. Continuing this success, her New York infirmary opened a medical college for women while under her sister’s charge in 1867. Dr.Blackwell continued to practice medicine, and in 1875, she became the professor of gynecology at the London School of Medicine for Women.

Throughout her career, Dr. Blackwell campaigned for the opportunity for women to practice medicine and for their acceptance in the field. She founded the National Health Society in 1871. Accorting to The Independent, “Blackwell had set up a private practice in London in 1870, established the London School of Medicine for Women in 1874 and finally won the right for women to undertake medical degrees in Britain during 1876 following years of campaigning.” She also released numerous pamphlets, brochures and books campaigning for women in medicine and documenting her experience. He publications include Medicine as a Profession For Women in 1860, Address on the Medical Education of Women in 1864, and Pioneer Work in Opening the Medical Profession to Women, published in 1895.







Insects and Disease

As the weather gets warmer, children play outside and insects find new meals. After the concerns for Zika virus over the past few years, there is heightened awareness for diseases passed through animal vectors.

Diseases such as Powassan virus are rising in incidence as the tick population grows and spreads the disease to new parts of North America. Although the CDC reports “100 cases of POW virus disease were reported in the United States over the past 10 years,” the illness caused by this disease can be extremely serious. While many people do not have symptoms, those who do become ill can develop neurological symptoms and difficulty breathing. What makes this so dangerous is that there is no cure and symptomatic treatment is not all that effective. Powassan and Lyme disease are not the only illnesses caused by tick bites. “Things such as babesiosis and anaplasmosis usually don’t have symptoms, just like Powassan, though both may cause severe or even life-threatening illnesses” (CNN). Rocky Mountain Spotted Fever is also often overlooked, but can be serious if not treated appropriately. In 2017, a woman affected by the illness lost her limbs to the disease. However, it is important to remember that although these infections can be very serious, the incidence of these severe attacks are rare. Rather than being afraid to play outside, knowledge about the disease and proper precautions are the best tools.

So, what research is being done to learn more about the illnesses passed to people through insects like ticks and mosquitos? An article on CNN this week reveals that a new study found a link between fetal brain development and certain viruses. If this sounds familiar, it should. This study expands on the knowledge that the Zika virus causes birth defects by testing the affect of other viruses on pregnant mice. The other viruses testes are chikungunya virus, Mayaro virus, West Nile and Powassan virus. West Nile and Powassan are classified in the same viral family as Zika. The study reveals that, “although all four viruses caused placental infection, only infection with the neurotropic flaviviruses (WNV and POWV) resulted in fetal demise.” Although it is not a causal link between infection and birth defects found in this study, there is definitely some sort of association.

How is it that we didn’t identify these links before now? Well, until the Zika epidemic, it was possible that there was not strong enough evidence to warrant a study. For instance, there may have been so few cases of Powassan that any defects that could be associated with the infection were overlooked because they were so few and far between. Additionally, it is possible that any of the defects that occur as a result from infection occur years later in development.

What can you do right now to limit your risk of exposure to these illnesses? Rather than staying cooped up in the house, take the right precautions. The CDC recommends that we wear insect repellant containing at least 20% DEET and you cover your skin with long clothing to prevent exposure. According to an article in Safety and Health magazine, tucking in these clothes and wearing light colors can prevent tick bites. There is even information on how to properly check for ticks. So, while we have not effectively eliminated these diseases, there are ways to prevent your exposure, which will limit your chances of developing a serious disease.

As awareness and research continue to grow, more resources and treatment methods will become available to protect the public from diseases and to treat possible exposures.


Serving the Medically Underserved

Many of us are familiar with discussions surrounding health care. Whether is pertains to insurance coverage, the cost of health care, the need for physicians or someone’s ability to access to health care, these discussions have been central to our political, social, and economic climate since the before the turn of the century. Why are these discussions so important? What is the basis of these conversations? Well, the most basic element in these discussion is about access to medical service. Meeting with a doctor that understands your culture, uses your insurance plan, or can provide care at a cost effective price is an irrelevant discussion is there simply is no doctor available for you to see. Areas of the country that have a shortage of physicians are considered medically underserved areas.

The Health Resources and Services Administration website states, “a Health Professional Shortage Area (HPSA) or a Medically Underserved Area/Population (MUA/P). HPSAs may be designated as having a shortage of primary medical care, dental or mental health providers. They may be urban or rural areas, population groups, or medical or other public facilities. MUAs may be a whole county or a group of contiguous counties, a group of counties or civil divisions, or a group of urban census tracts in which residents have a shortage of health services. MUPs may include groups of persons who face economic, cultural or linguistic barriers to health care.” Although health professional shortage areas and medically underserved areas are similar, there is a fine distinction in how they are defined.

A health professional shortage area includes shortages in primary care, mental health, or dental care. It includes functioning facilities such as hospitals, clinics, correctional facilities, and community health centers that have a shortage of providers. Nationally there is an approximate shortage of 7,167 doctors. However, this estimate may be vastly underestimated, as programs such as the American Medical Association previously estimated a shortage of 62,900 physicians by 2015. These shortages are located all over the country. In face, a map of Health Professional Shortage Areas shows that almost every state is affected by a physician shortage and well-served and underserved areas can be right next to each other. The Federal Register website even recognizes entire states as medically underserved in the Federal Employees Health Benefits. These states are Alabama, Arizona, Idaho, Illinois, Louisiana, Mississippi, Missouri, New Mexico, North Dakota, Oklahoma, South Carolina and Wyoming. There are equivalent maps of dental care and mental health care shortage areas also on the HRSA website.

Medically underserved areas are designations for areas of the population that do not have adequate access to primary care medical services. It is important to note that these medically underserved areas are not evenly distributed throughout the population. Some subsets of the population are more negatively affected than others. Populations that have increased barriers to healthcare such as economic, cultural, or linguistic barriers are groups such as the homeless, members of low socioeconomic status (low-income, Medicaid users), Native Americans, and migrant farmworkers. While these populations are not the only groups affected, their difficulties in accessing medical care are disproportionately larger than other groups. If you are interested to see if you live in a MUA, you can search your for your county’s information here.

Who is most likely to want to work in these areas? However, it is important to note that there are a few predictors of the types of physicians willing to work with underserved populations. A study titled Working with the Medically Underserved states that these factors are, “being a member of an underserved ethnic or minority group, having participated in the National Health Service Corps, having a strong interest in practicing in an underserved area before attending medical school, and growing up in an underserved area.” It is important to note that this is a subset of the medical professional population. Physicians are not the only providers working to increase access to care. As of 2016, 63.4% of the 153 of the nurse led health clinics associated with the National Nursing Centers Consortium are located in underserved areas. However, not every provider (nurse, physician, nurse practitioner, physician assistant, or otherwise) wants to work in these areas. Thus, there needs to be a draw or incentive to attract them.

So what is being done to address the need? There are a number of incentive programs that are designed to attract physicians to need areas. For example, there are scholarship and loan repayment programs, bonus payments from the Center for Medicare and Medicaid Services and better reimbursement rates for physicians practicing in rural health clinics. Additionally, studies have shown that when medical schools partner with free clinics, there are benefits for both parties. This is a potential solution for closing the gap in these medically undererved areas, because “students exposed to underserved populations may be more likely to pursue primary care fields and practice in underserved communities, improving health-care infrastructure.” Even now, medical schools offer information for students interested in these areas. Case in point, University of South Florida has a handout available to students. However, they have to seek the opportunity themselves. Although this type of solution does not offer instantaneous results, it may produce longevity. Physicians my develop an interest in working with underserved populations while in school, producing a change in career goals and interests, rather than working in underserved areas as a temporary solution for loan repayment.