The Black Belt

Tuscaloosa, Alabama, a big small city an hour west of Birmingham. It is home to the University of Alabama and their Crimson Tide football team. This town has Jesus and it has football. Depending on the season, the shouts of “Roll tide!” ring out louder than the bible-thumping “Amens!”

I went to Tuscaloosa from New Orleans for four weeks of my family medicine rotation. Family medicine is the specialty that promises a bit of everything: old, young, chronic and acute. Not only was I going to ‘see it all’, but I was going to see it in what Dr. G described as the Black Belt. That term captures an entire history in its two syllables, at once describing the land’s rich soil, the localization of enslaved peoples, the horrors of lynching, the terrorization of black bodies, and deep rural poverty. It is a poverty described more by what it lacks (education, employment, resources, food…) than what is contains in its dark shadow. It is these hidden truths Dr. G referred to: the medical atrocities seen in such poorly tended to areas – areas where terms like “health care” and “doctor” feel foreign to the twang of a southern tongue. Here patients’ medical needs span a wide range: from childhood vaccinations to pap smears, from sports injuries to chronic pain management, from mental health crises to hospice care, and, perhaps most difficult of all, drug addiction. 

Halfway through my medical training, I had not come across the opioid epidemic in practice. Everything I knew about addiction and the epidemic came from the news or lectures. I had learned to identify common drug-seeking behaviors and how difficult effective treatment is. I had no idea what to expect.

Indeed, what I saw was surprising. It wasn’t the patient who came for painkillers even though she had gotten more than 20 prescriptions filled in the last month, nor the patient with questionable chronic pain that seemed to migrate each time she described it, nor the family histories counted by drug-related deaths and incarcerations. What surprised me the most was the ripple effects of this drug epidemic – the way it wrote itself into nearly every patient’s medical chart. It was a communicable disease. It infected those closest to the source, particularly children, whose immune systems had not matured enough to fight it off.

One afternoon I sat in at the psych clinic for pediatric consults. They were all virtual, using high-tech video conference calls projected onto a large screen. Once connected, it showed two chairs in a cinderblock room in a town somewhere in the Black Belt where psychiatrists were nowhere to be found. One chair was for the patient, one for the guardian.

The first patients were siblings, a seven and five-year-old brought in by their grandparents. They were their unofficial guardians since “their mama don’t want them back,” the grandma said, while covering the older brother’s ears. Both kids were coming in for behavioral problems at school. They were bullying other kids, yanking out hair, touching inappropriately, and the list went on. On top of this, the boy had ADHD and the little sister recently started binge eating, shoveling food until she threw up, pausing momentarily only to resume eating again. The grandparents felt hopeless and at a loss for what to do. But, after Child Protective Services removed the kids from their mother’s house with signs of physical and sexual abuse, there was no way they would let them go back there. “It wasn’t their mama though”, grandma assured. “She’s a drug addict and all, but it wasn’t her. It was that good-for-nothing boyfriend living there.” She asked the kids if they remembered him and what he did to them. They both shook their heads and giggled, fussing in their seats, the girl slowly sliding herself to the floor. The grandma sighed. She knew they knew. They had already told her, told the police, told the doctors in the ER who prepared the rape kits.

How could they forget? Forget events traumatizing enough for anyone to remember? But they were not anyone. They were children. Children are resilient and creative in how they hide their memories. Children change their behaviors to fill hidden gaps, to communicate the words they are too young to understand.

But it was not just age that limited them, as the subsequent 15-year-old patient demonstrated. He came with his father for ADHD and general behavioral problems. The father did most of the talking. “When we got him, he was five years old and weighed only 30 pounds. The foster agency said his birth mother would lock him and his baby sister in a room for days a time. She would leave, going off to do who knows what kind of drugs.” The boy sat quietly beside him, head hung over his lap as he slowly twiddled his thumbs. He had no visible reaction to the comments made. Perhaps it didn’t bother him to hear this, to be reminded of his childhood traumas. Perhaps he was used to it. Perhaps it didn’t seem so different from the experiences of other kids around him, like the kids in uniform outfits occasionally walking past the window behind him.

It was a window that looked into a colorless, fluorescent-lit hallway. This room was a counselor’s office at a juvenile detention center, a room whose protective walls seemed destined to swallow these children and spit them out on the other side. Once outside, they would join the kids wandering the hallways, occasionally gathering by the fountain for water, gossip, or flirtation before getting caught by the guards watching over them. These were guardians of a sort – not like the family members or foster parents who once sat lovingly beside them. Rather, these were guardians whose affection is used to prevent suicides or break up fights and whose goodnight tuck-ins check that each cell is safely locked – safe from each other, safe from themselves, and, just maybe, safe from the deadly epidemic whipping its black belt against the walls outside.

Alana Carstens is a 3rd year MD/MPH student at Tulane University School of Medicine.  She’s interested in obstetrics and gynecology and is passionate about increasing access to healthcare and issues of reproductive justice. When she’s not working, she can be found dancing, baking cookies, or planning next year’s Mardi Gras costume. For more by Alana, check out and subscribe to her blog.