The Joseph F. Sullivan Center has performed health outreach in rural communities on behalf of Clemson University for nearly four decades. As part of the Clemson University College of Behavioral, Social and Health Sciences (CBSHS), the center has acquired improved outreach vehicles and expanded its staff, and leadership in the college are continuing that growth in order to meet the needs of rural populations.

According to Ron Gimbel, chair of Clemson’s Department of Public Health Sciences and director of the Sullivan Center, that growth is no longer limited to what a single center can do; if anything, Gimbel envisions the Sullivan Center among many as a spoke on a wheel. The hub of that wheel is a new, comprehensive infrastructure of programs and services dubbed Clemson Rural Health, which Gimbel said acts as an organizing framework for health service delivery and clinics as well as collaborative work involving health outreach and community development projects.

“The Sullivan Center’s modernization and expansion along with the numerous outreach projects coming up and underway in the college made it clear there was a need for an ‘umbrella’ under which all of these initiatives could be organized,” Gimbel said. “We have a proven track record in the area of rural health outreach and mobile health delivery and the need is certainly there and greater than ever before; it’s time we expand to meet it.”

Seeing an evolution

Caitlin Kickham initially began volunteering on the Sullivan Center’s mobile clinic in 2010 in order to retain the Spanish she had learned in her undergraduate studies. Little did she know that she would witness the evolution of CBSHS health outreach as she herself evolved from an undergrad volunteer to a family nurse practitioner and the Sullivan Center’s director of outreach and wellness. There were obviously a few graduate degrees earned along the way as well, all of which came from Clemson.

Taylors Free Clinic

Logan McFall, a health educator in the Sullivan Center, parks and sets up a mobile clinic in Taylors, SC.
Image Credit: College of Behavioral, Social and Health Sciences

Kickham said she has always been preoccupied with logistics, and the outreach work in the center provided her no shortage of opportunities to improve processes or solve problems. Improving processes on the mobile clinic and in the Sullivan Center, streamlining paperwork and expanding outreach opportunities when the clinic still relied on an aging mobile unit all fed into the Sullivan Center’s mission.

“Maintaining relationships with clinics we visit and growing new partnerships is still a lot of what we do,” Kickham said. “Closing health care needs gaps, delivering needed services to people directly, and connecting them to other services they might need — ­these are all services that have always been needed. We just have a larger, more diverse team of people to better accomplish those tasks.”

According to Gimbel, Clemson Rural Health aims to make a positive, measurable difference in three primary health areas. It seeks to reduce preventable hospitalizations by addressing prevalent, chronic diseases such as hypertension and uncontrolled diabetes in rural areas.

Clemson Rural Health also works to enhance healthy behaviors that include diet and exercise and the reduction of unhealthy behaviors such as excessive alcohol use. Education aimed at reducing teen births and sexually transmitted diseases falls into this work as well.

The third and final major health area the program addresses is a reduction in premature death, which it defines as deaths in people under age 75. The causes of death correlate with those health issues the program is targeting to reduce preventable hospitalizations.

Clemson Rural Health has expanded in the past few years from one large mobile health clinic to five mobile health units. The large mobile clinic still offers numerous services and can transform from one large meeting room into several individual patient rooms, but the additional, smaller units offer targeted health services such as mobile mammography.

Taylors Free Clinic

Kristie Boswell (left), family nurse practitioner and clinical instructor, prepares two students from the Clemson School of Nursing for a free clinic appointment.
Image Credit: College of Behavioral, Social and Health Sciences

Clemson Rural Health also features an expanded staff that includes Marvina Jones, manager for rural health and community development, whose extensive logistics background in the U.S. Air Force has already helped the program increase its footprint in the Upstate. Brooke Brittain, another recent addition to the Clemson Rural Health team, brings extensive experience and education in nutrition as the team’s first dedicated dietician. Kathleen Cartmell, who joined the public health sciences faculty in 2019, leads cancer prevention efforts as part of the Clemson Rural Health team.

Kickham said the outreach teams in years past managed to offer a long list of services to rural areas, and the addition of mobile units and specialized staff have only strengthened those offerings. Expanded billing capabilities allow the units to accept a variety of Medicaid and Medicare programs as well as private insurers.

“We still go into areas and offer a full range of support because that’s often required,” Kickham said. “From there we adjust what we offer when we see what people need and what they are motivated to do. Sometimes we have to connect people to food pantries or other services that meet their most basic needs; honestly, people aren’t going to be motivated to eat healthier or exercise when they don’t know where their next meal is coming from.”

‘The Tiger showed up’

“They say ‘you can never go home again,’ but you can,” Connie Normand said, chuckling. “Hurricanes can send you back home.”

Normand grew up in Abbeville County, but she worked her entire professional life in Baton Rouge, Louisiana, as a nurse. She had no plans to leave Baton Rouge until Hurricane Katrina swept through and made that decision for her. Katrina—along with health issues some of her family members were facing—made it clear that Normand would be returning home.

Normand has been back in Abbeville County for 15 years now. When she first returned, she was struck by how little it had changed since she left in the 1970s, for better and for worse. The small-town charm was still there, but with it came the health disparities that were simply more visible to her after years as a health care professional.

In 2009, United Christian Ministries opened in Abbeville County to aid people in financial need. When talk of adding a free clinic soon followed, Normand raised her hand thinking she was volunteering to help. In actuality, she volunteered to be the clinic’s director.

In the 10 years since, Normand has seen how Abbeville residents have come to rely on the free clinic when they cannot afford medical care or simply have trouble accessing it. However, even though the clinic does “a lot with a little,” it requires a safety net at times, and that’s how Normand sees the clinic’s long-standing relationship with Clemson University and the Sullivan Center.

Taylors Free Clinic

Logan McFall (right) takes a blood pressure reading for a patient from the Taylors Free Clinic.
Image Credit: College of Behavioral, Social and Health Sciences

“The mobile clinic has been a godsend; we asked for help and the Tiger showed up,” Normand said. “For us, they truly supplement what we do and meet so many needs for everyone we see in a single visit. The services they provide specifically for women, such as pap smears and mammography, are especially vital because we simply can’t provide them, or we would have to refer residents elsewhere to get them.”

The Abbeville free clinic is just one of more than 40 rural outreach clinics; which include hospitals, family practices, community centers and farms; that Clemson Rural Health currently conducts. Some areas have greater specific needs than others, but the barriers that Normand describes for the people of Abbeville County are largely the same across South Carolina.

She talks of the lack of transportation as a barrier to care and about the long-held mentality of many rural people to “take care of themselves,” something that many don’t see as a flawed way of thinking until after the damage is done to some crucial area of health. This is why education folded into routine visits and screenings—an attempt to affect long-term thinking about health while fulfilling a short-term need—is so important. Normand said she has seen firsthand how Kickham and other Clemson Rural Health employees have always factored this information into each visit without coming across as preachy or condescending.

Normand’s concern for the most vulnerable people of Abbeville County has only grown since the COVID-19 pandemic “stopped the world.” However, despite how much COVID-19 has derailed the lives of people across the globe and even in Abbeville County, she said there may be a silver lining in the long run.

Normand feels that people may finally start to understand that rural health issues touch the lives of everyone. When someone in a rural area goes without health services or screenings to the point that their first point of contact is an emergency room to address something that could have been prevented, it’s a stress on the entire health care system.

“That affects everyone in a roundabout way,” Normand said. “Maybe now people won’t be able to turn a blind eye so easily. Maybe a pandemic that affects everyone will cause people to take a look at the health issues that weren’t talked about or recognized before.”

The future

When Gimbel and CBSHS Dean Leslie Hossfeld were busy laying out the overall plan for Clemson Rural Health, coronaviruses weren’t widely discussed outside of infectious disease circles and clinicians. However, Gimbel and Hossfeld recognize that COVID-19 has become a formidable threat to rural health, so the priorities for Clemson Rural Health have evolved to reflect it.

COVID-19 is certainly a cause of premature death. Steps to reduce its transmission have been shown to reduce preventable hospitalizations. Enhancing healthy behaviors such as good hand hygiene and social distancing have proven to be a key in reducing the spread of COVID-19. At this point, not factoring COVID-19 into Clemson Rural Health would be like trying to ignore heart disease or cancer.

Thanks to funding from the Healthy Me – Healthy SC program, Clemson Rural Health has fielded a dedicated COVID-19 screening team in rural areas since August 2020, which will include newer mobile health units that are tailored to support the lengthy COVID-19 recovery period the state will soon face. Hossfeld said that on top of the rural health outreach that was already planned in Clemson Rural Health, much of the program’s work in the 2020-2023 timeframe will be related to COVID-19 recovery.

Clemson Rural Health is a vital part of the college’s Building Healthy Communities, a college-wide initiative designed to improve the health and well-being of people across South Carolina.

Hossfeld said that directly addressing the need for COVID-19 testing and the other prevalent health issues rural communities face is an important part of this larger initiative. She believes that it positions CBSHS as an example of what a 21st century land-grant college is capable of accomplishing.

“The health issues that threaten rural communities didn’t pause because of COVID-19; they’ve only become more pronounced,” Hossfeld said. “As a rural sociologist, I know the challenges these communities face, and ensuring a healthy community is a key to economic development. We have an opportunity with Clemson Rural Health to continue addressing these issues along with COVID-19 so that rural populations don’t continue to suffer unnecessarily.”

Taylors Free Clinic

Student learning is one of the top priorities during free clinics, so students in various Clemson departments are allowed to directly engage with patients in order to gain hands-on experience.
Image Credit: College of Behavioral, Social and Health Sciences

Kickham doesn’t need to guess about worsening conditions for rural citizens; she sees it during every clinic and every stop that the mobile units make. She points to the screening questions the clinics use regularly to gauge need and priorities in each area. The results of the last several in each location have been telling.

Kickham said in the last three months, the rates of people saying they are food insecure has exponentially increased. Before COVID-19, these screeners would reveal one or two individuals a month who reported that they didn’t know where their next meal would come from. In the last three months, that number has jumped to 90 percent of the patients they saw in Abbeville County.

“Considering we see those patients every quarter, that jump can only be attributed to COVID-19,” Kickham said. “Like it or not, it’s going to affect the rest of the outreach work we do for a long time.”

Gimbel said Clemson Rural Health is designed to adapt in this way to existing health issues and new issues that arise. Rural populations in South Carolina and the health issues they face are diverse by nature, so the framework of Clemson Rural Health cannot afford to be rigid.

Detailed studies of food insecurity completed in Pickens and Oconee Counties—as well as secured funding to study many more counties in the same way—are helping the college understand the issues as it implements solutions. These outreach programs are informed by research, and they simultaneously engage current Clemson students with practical learning experiences.

A chronic health issue such as uncontrolled diabetes in one county may need immediate attention while another county struggles more with hypertension. Gimbel said these differing needs demand a staff and a framework that is big enough to cover all the areas of need and nimble enough to adapt and respond in kind.

Gimbel said the Connie Normands across the state shouldn’t have to hope these services will be available; an organized framework of health services such as Clemson Rural Health is designed to deliver them.

“We’ve spent decades meeting these populations where they are and addressing their needs directly or connecting them to health care systems that otherwise wouldn’t know they existed,” Gimbel said. “We can do that more effectively with an expanded staff and a larger geographic footprint, which is why we are so excited about what is in store with Clemson Rural Health.”