A Healthier Waco

By Kevin Tankersley

One neighborhood at a time

Sitting right next to the Brazos River on Waco Drive is the Waco-McLennan County Public Health District. Chances are you’ve never stepped foot in the building. Director Sherry Williams says most people don’t know the public health district is there until a need arises. But day in and day out, her team of nurses and staff provides for Waco by giving immunizations, inspecting restaurants and public pools, monitoring tuberculosis cases and more. They have a pulse on what the health needs are for the community with strategies to see improvement in those areas. They also prepare for the worst, like the spreading of the Zika virus.

Williams has been part of the Waco-McLennan County Public Health District for nearly 35 years. She began as a public health nurse, was director of the public health nursing division and has been director of the district for five years.

Williams graduated from Jefferson-Moore High School and received a bachelor’s in nursing from the University of Mary Hardin-Baylor; she also completed the women’s health care advanced nurse practitioner program at the University of Texas Southwestern Medical Center. She was the first person to receive the Janet Emerson Public Health Servant Award, presented by the Texas Association of Local Health Officials in 2006. She serves on numerous boards and committees, both locally and around the state.

Wacoan writer Kevin Tankersley met with Williams to talk about what the public health district does for the community and some of the initiatives that are in progress right now.

WACOAN: What does the public health district do?

Williams: In public health, we have environmental health where we inspect restaurants to make sure the food supply is safe. They do on-site sewage facility inspections. So when people build homes out in the unincorporated areas, they’re responsible for making sure the septic systems are installed correctly. They also inspect public pools in hotels and spas.

We have vital statistics. That’s where we register births and deaths in the city and county. People can come in and get copies of birth and death certificates. If they were born in the state of Texas, they can come in and get a copy of their birth certificate. We have a connection to the database at the Department of State Health Services in Austin. If they die in the city of Waco, we have access to those records.

We have a WIC program, which is Women, Infants and Children. It’s a nutritional supplement program where families can come in, based on their eligibility, and receive education about nutrition. Then they get a card they can take to the grocery store and buy certain food packages to help supplement their diets.

We have [an HIV/STD department], where we screen people for sexually transmitted infections. We can treat them as well. We have medications. The nurses who work in the clinic actually do the treatment. We don’t have a public health physician on site 24/7, but we do have a physician who is our consultant. He comes in once a week to make sure the clients are receiving appropriate care.

We also do screening and testing for HIV. When we find positive folks, then we try to connect them with our case management program to make sure that they receive the care that they need to live as normal a life as they can.

And we have public health nursing. I saved it for last because they do so many different things. They are responsible for immunizations. We provide immunizations to people pretty much on a walk-in basis. We do all of the routine childhood vaccinations as well as foreign travel vaccinations.

We work with local clinics and providers to make sure they are aware of all the changes that occur with immunization practice, because they do change quite often. We provide education and support for that.

We do [tuberculosis] prevention and control. We see clients who have actual TB infection and TB disease. There’s a big difference in the two. TB infection means they’ve got the bacteria in their bodies, but it’s not active and they’re not infectious — they can’t give it to anybody. We encourage those folks to do preventative treatment.

Then we have the folks who are TB diseased. That’s where it is active TB, and they are contagious. They are required by law to be treated. We let them know that right up front. We have medications that we provide in both instances to the clients.

For the cases for active TB, if they become noncompliant or we feel like they’re not going to do what we need them to do, we can take them to court and get a court order to quarantine them. We still do have quarantine hospitals for TB in San Antonio. For folks who are noncompliant, they have to go there and be treated. It’s a locked facility. We have another facility in Tyler that’s for more complicated cases, like if the drug we have here locally is not working, we can send them to Tyler. The hospital in Tyler has physicians to work with them and try to figure out what treatment plan is going to work. We work closely with the state on those cases as well as with those two different hospitals.

WACOAN: How do you determine if someone with TB needs to be taken to San Antonio? What clues do you look for?

Williams: If they’re not coming in and taking their medicine.

What we do with the cases is called directly observed therapy. We go wherever [the clients] want us to go. We’ll go to their homes. We’ll go on their jobs, once they’re able to go back to work. They’re usually on treatment for at least six months, sometimes longer.

Usually when someone is diagnosed with TB, we test them every week until we know they’re not infectious anymore. As long as they’re infectious, they can’t go to work or anything anyway. More than likely, we’re going to go to their homes and give them their medicine every day and watch them take it and make sure they’re doing OK.

Once they get past that contagious state, then we will allow them to go back to work, but we still have to give them their medicine every day. We can go on their job. We can go to their home. We can go wherever they want to meet us. We do watch them take their medicine, so if they decide they’re not going to do that anymore before their treatment plan is completed, we try to work with them as much as we can.

We try to be as flexible as we can in meeting them and trying to make sure they take it and encouraging them to do so. But at some point if they decide they don’t want to do that, then we can take them to court and say, ‘This person is a threat to the community because they do have an infectious disease and they need to be on medication and they’re not following through with what we recommend that they do.’

WACOAN: Does the health district have one clinic, or are there more?

Williams: We have different clinics. They’re all in the health district building. We have one clinic site.

WACOAN: Are there eligibility requirements people must meet to come to the public health district?

Williams: Most of the services are for residents of McLennan County. The immunizations, we will see anybody because we receive the vaccines for the most part from the state of Texas. Routinely, it’s McLennan County residents.

WACOAN: How do you go about getting out in the community and letting people know what the health district does?

Williams: We go to a lot of health fairs. We try to go to community events that are out there and will allow us to come. We go to different churches. We go to PTAs. We’ll go anywhere. We put ourselves out there. Some folks will have us on a routine basis, and some we learn about from other agencies.

WACOAN: So it appears that the health district provides both treatment and education?

Williams: We have a health education division. Their job is to be out in the community talking to people about whatever they want to know about. We might get a call from someone to come and talk about hypertension or come and talk about diabetes or come and talk about healthy eating. We go out and do those kinds of educational events. That is the group that coordinates our health fairs.

We try to do a huge [health fair] in April in conjunction with National Public Health Week. We partner with different groups, and traditionally, we’ve gone over here to the Multipurpose Center in East Waco. There are other vendors there: community agencies, healthy food tasting, exercise. It’s just a huge event. But we do go out in the community quite a bit.

We have an epidemiology department that’s responsible for disease surveillance and investigations and reporting. They work a lot with the hospitals and clinics to receive disease reports. We have a list of what diseases we report and what we do [to respond]. When we get food outbreaks and suspect a foodborne disease, we have to try and find all of the people who may have eaten at that restaurant and gotten sick and figure out if they were part of it or not. That can be quite intensive. We do that in conjunction with our state and local partners.

One that we recently worked, we had some band kids who came to Waco, then some of them got sick after they ate at a local restaurant. We had to go out and investigate the restaurant, and we found there really wasn’t anything at the restaurant that made the people sick, but we still had to find all these folks to ask, ‘Did you get sick? Did you not get sick? What did you eat?’ That was all part of the investigation.

WACOAN: What other diseases do you report?

Williams: There’s a whole list: measles, mumps, rubella, shigellosis, the sexually transmitted diseases.

WACOAN: Is the purpose of tracking these diseases just to keep data or to keep them from spreading or something else?

Williams: It depends on the disease. Some of it is for data purposes. Some of it is preventative because we don’t want other folks to get sick, so we try to find folks who are sick.

Like with hepatitis, we want to find folks who have potential hepatitis and prevent them from spreading it to other folks. We’re going to be a little bit more aggressive in trying to find them. With the foodborne, of course we want to find them, but sometimes it might take us a little bit longer.

A lot of the diseases have already defined timelines of what is expected. If you’ve got a case of measles, you need to be on that, like now. We certainly want to prevent the spread of measles. And we can, but we have to know about it first. Once we know, we’ve got to get on the wagon.

But there is a list of reportable conditions, and on that list, it tells what’s reportable in so many days, or so many hours, or whatever it might be. And it is on our website.

WACOAN: Do you think there are any misconceptions in the public about the health district and what y’all do?

Williams: I don’t think there are any misconceptions. I think the thing is they don’t know that we’re here, and they don’t know what we do. Once we tell them what we do, they say, ‘Oh, wow. I didn’t know y’all did all of that.’ We’re our own best secret.

The thing about public health that I’ve heard, and I happen to agree with, is that the community doesn’t know you’re there until something [bad] happens. Then when something happens, we’re right there. We’re trying to change that. We want the people to know we’re here before something happens.

WACOAN: Last year, Baylor’s Center for Community Research and Development compiled a Community Health Needs Assessment, the first survey of its kind since 2013. There’s a lot of information in that 200-page document. Was there anything surprising you learned from that survey?

Williams: It really kind of confirmed what we were already doing and what we already knew. The health district has traditionally done a community health needs assessment every five years. When the rules changed for the hospitals that they had to do them every three years — in 2013 — they came to us and asked if we would do one every three years. We did.

When we did the one in 2013, the main areas that popped out at us then were obesity, women’s health, access to care, mental health and dental. Once we identified those top priorities, we then met as a community to ask what we were going to work on. You could work on all of these all of the time, but you’ve got to focus your energies on something. It was women’s health, access to care and obesity.

When we did the survey this year, we did it a little bit different because we have different folks we work with. The assessment before, we worked with the University of North Texas. This assessment, we worked with Baylor. We wanted to know a little bit more information that was not in the 2013 assessment. It’s not just the health department. It’s the community: hospitals, family health services, the health district and some other agencies. In the 2016 report, there’s some data that can be compared to 2013, then there’s some new data that will be the baseline.

The 2016 assessment confirmed that we’re on the right track, and we’re looking at obesity, healthy eating, healthy living, access to care, women’s health, mental health. We’ll continue to focus on those areas. And some things we are doing better, like access to care in terms of insurance coverage — those numbers did improve. We’re not sure what that’s going to look like with the new [presidential] administration.

WACOAN: I read that the public health district is one of 50 finalists nationwide for the Healthiest Cities & Counties Challenge. The goal is to increase access to healthy foods within the three ZIP codes which have increased obesity rates. How do you go about addressing that?

Williams: What we’ve done is we went to each of those ZIP codes —

WACOAN: What ZIP codes were those?

Williams: We went to 76704, 76706 and 76707. We went door-to-door and did surveys. We asked folks questions about how much they exercise and how long do you do it, what kinds of food they eat, how many servings of vegetables they eat. Then we asked them what were areas of concern for them and their neighborhoods.

We did focus groups as well to find out what people think and what they think some possible solutions were. We were working with the neighborhoods to try and address those concerns and identify strategies that the community can do.

For instance, over in East Waco one of their concerns was having a safe place to exercise. So we used some Texas Healthy Communities funds that we received to work with the [Doris Miller Family YMCA] in East Waco to put in an outdoor track where people can go and walk. It’s lighted. It’s safe.

There was some concern about access to healthy foods. We worked with the Veggie Van to have more locations in East Waco where people can go and purchase healthy foods.

We are going to be working with the Parks and Recreation Department to implement some signage in some parks around town. If people want to go there and walk, sometimes they want to do something different. So we’ll have signs in the park that say you can do 20 pushups and you’ll burn off so many calories. They’ll give people different options other than just walking.

It’s whatever we can do with the support of the community because we don’t want to go in and tell people what they need to do. We already know that doesn’t work. We want to work with the community.

WACOAN: The health district had a hand in the new Jubilee Food Market that Mission Waco recently opened.

Williams: We worked with them to help make that happen as well. We have some staff working with Mission Waco folks. It’s really a community effort called Live Well Waco that has been in existence for close to 10 years now. Now it’s under the umbrella of Prosper Waco.

We realized that we’re all trying to do the same thing, so there’s no need for us to all have our own little pieces. We can put our pieces together and be more effective. So Prosper Waco and Live Well Waco — all those folks working together — helped bring the grocery store to Mission Waco.

The health piece of Prosper Waco really adopted the work that we were doing, what we were calling a Community Health Improvement Plan, or CHIP. They adopted the work that CHIP was doing, and that became the health piece of Prosper Waco.

WACOAN: Back to the health district’s emphasis on obesity. I’ve seen media reports that say Americans are getting fatter and fatter. Is that what you’re seeing in Waco and McLennan County?

Williams: Unfortunately, yes. In the assessment, looking at [body mass index], the percentage of folks who were normal weight remained about the same. The [percentage of] people who were overweight decreased, but the obese increased. We’re not sure what that means. The healthy didn’t change that much, so it didn’t look like they moved there. It all seems to work together. The healthiest cities challenge, we read what they were wanting to do, it kind of fit what we were already doing.
WACOAN: What all is involved with the healthiest cities challenge?

Williams: There are five domains that they look at, and healthy behaviors was one of them, which is what we chose to work on. It’s a two-year project where you work on improving whatever your goals are. We had to tell them what that is, and ours is working on healthy eating. Then you work on it.

They give you $10,000 seed money to bring people together to work on it, bring people together to do planning and things. Then after a two-year period, they’ll come and assess us and see how well we did and determine if we’re the winners. For the tier we’re in, based on population, there’s a $250,000 first-place prize and four $25,000 runners-up. But we’re going for the $250,000. We want to win.

WACOAN: A year or so ago, the Zika virus was all over the news but hasn’t been much lately. Is it still a concern?

Williams: It’s still a concern, and we’re still doing planning for Zika. Down in South Texas, in Cameron County, they did have the first local transmission — a mosquito biting people. There’s an association of local health directors, and we talk often. We were on a call last week with the director down in Cameron County, and she was telling us about their experience.

We are always planning for things to happen and hope they never do. We have a Zika response plan in case we get some local transmissions here. We’ll try to identify the area, the community, then go door to door talking to folks.

In Cameron County, they actually tested people as they went through [the community]. They drew blood as they went door to door to try to find if a neighborhood had Zika or not. That’s how they found it. We do have those planning activities going on.

WACOAN: So kind of a basic question: What is Zika?

Williams: It’s a disease that is basically carried by mosquitos that causes in the general population flu-like symptoms. But for [child-bearing women], it causes some grave consequences for the baby. It can cause babies to be born with microcephaly. That’s the biggest deal right now.

The real emphasis is for women of child-bearing age to avoid getting bit by mosquitos. We [would normally] try to encourage them not to go out at dark, but Zika mosquitos bite all day long. The mosquitos are day-biters. I’ve learned more about mosquitos than I’ve ever wanted to know.

So our emphasis is on child-bearing-age women. Don’t go to Miami if you don’t have to. Don’t go down in the valley if you don’t have to. We know that it’s there. If you want to avoid it, stay away. It can also be sexually transmitted. That [same advice] goes for spouses of women of child-bearing age. If the husband gets it, then he can infect the wife. It’s a lot of prevention, a lot of education.

We don’t have any cases of local transmission in the state other than Cameron County. However, there are people who have been diagnosed with Zika in the state of Texas.
But they have gotten it [in other locations] and brought it back here. It wasn’t acquired here. That’s why we tell people who have traveled to these places to stay inside, try not to get bitten.

If it’s in your body and a mosquito bites you, then the mosquito bites someone else, that’s how it becomes a local transmission. It’s not that it’s [always] passed person to person, but if I have Zika and a mosquito bites me and then he goes and bites you, then your chances of getting Zika are increased.

We do work with Baylor, and they are the ones who do our mosquito trapping to see what type of mosquitos we have and if they’re the type of mosquitos that carry Zika. And right now, we don’t have any that have Zika in the areas that we’re testing.

WACOAN: What else do I need to know? You’ve given me a lot of good information.

Williams: We were very proud to work with the American Heart Association and the smoke-free Waco folks to get the smoke-free city ordinance about a year ago. We were really pleased to be a part of that. I had to present to city council several times and get them the information that they needed to be able to make that decision. We were very proud of that.

WACOAN: That was a good thing to happen.

Williams: And we’re a health district, so we’re trying to work with our other member cities to implement the ordinance as well. So far, Lacy Lakeview has. Woodway and Hewitt are talking about it. Hopefully over the next few years we’ll get them all on board.

WACOAN: Are your partner cities all the towns within McLennan County?

Williams: Yes.

One additional thing is that in our strategic priorities, one of our priorities is to ensure health equity. And equity and equality are different. Equality means that it’s equal for everybody. Equity means that people who need it the most get what they need. That’s why we’re trying to work with our community partners in our neighborhoods to ask the question, ‘What do you need?’

The neighborhoods are different, and they’re going to need different things. We don’t want to say, ‘Well, we did this over here, so we’re going to do it over here for you, because that’s what you need.’ That’s not necessarily the case. We’re trying to focus on equity and working with people on what their needs are and trying to meet them where they are.