PRESENTATION TO MOSES CONE FOUNDATION SPECIAL POPULATIONS ACCESS TO CARE TASK FORCE, OCT 30, 2013, ON A PLAN OF ACTION TO MOBILIZE REFUGEE COMMUNITY HEALTH WORKERS (PROMOTORAS DE SALUD).
The Special Populations Task Force has been meeting for a long time. It focuses on two exemplary populations in the area, Latino and Montagnard. In September we were delighted to view a TED presentation featuring Dr America Bracho on the value of community health and the promotoras model. But as we sought to explain in the brief ensuing discussion, we showed the wonderful Bill Moyers’ PBS video Santa Ana Health Crusade that first brought to national attention Dr Bracho's work to our Montagnard promotoras three years ago.
So, after submitting our own Plan of Action that showed how Montagnard community health workers could be integrated with US-trained Montagnard health professionals and Montagnard former MDs, I was invited to give a brief presentation about the proven track record of community health workers.
On my flip chart I outlined 5 points:
(1) $10 was the rate of pay acceptable to Montagnard moms and grandmothers. This is better than the paltry $7.25 paid in factories and warehouses but still represents a poverty income. David Fraccaro of FaithAction interrupted to say that they sought to pay community health workers (CHWs) $12-13 which I applaud.
A Moses Cone Health System billboard used to proclaim that its system had "1000 skilled physicians". Upon reflection, our CHWs wondered what good were any of them to the community? We imagined the salary of one doctor and how many CHWs could be deployed with that salary and how much benefit the community could enjoy. Unless health professionals and the Greensboro community are willing to listen to social justice arguments for these kinds of comparisons, there will always be clever counter-arguments and reasons not to invest in preventive care and community health.
As I reminded the room of experts, the CHW model is not new and has already been proven to work in both targeted (and very different populations), Latinos and Montagnards. Frustrating? Yes! Many indeed know CHWs are cost effective, but fighting for nickels and dimes to pay for a few when we need dozens and scores of CHWs is not a battle that will change community health.
(2) Health benefits. Our CHWs were paid by scraping together grant and research money in a stop-and-go fashion, so no benefits for them. Sustainability requires benefits.
(3) Poor people require a gas and phone allowance. We covered these costs whenever we could.
(4) As community members, mothers and grandmothers, CHWs are “force multipliers”. Compared to the health systems solutions, CHWs provide a huge bang for the buck. So why don’t we enlarge the tiny programs that have a proven record of success here in Greensboro? Most mainstream, middle of the road leaders are gradually drawing the same conclusions about the region: We're too slow, too conservative and established powers are too entrenched to change in the face of overwhelming evidence. Even during the Great Recession leadership found reasons to dig in their heels rather than use the opportunity to change. So instead of innovation and timely intervention, regional leaders preferred to close Healthserve! Then everyone had to listen to an embarrassing, enraging, and unsatisfying set of rationalizations and rah-rah public declarations by responsible parties about how this was good for the poor and sick people of the region.
(5) The community health worker model is ultimately grassroots with its members more loyal to their community than to big health institutions, systems and cultures which have traditionally excluded them. Admitting large numbers of CHWs into the current local system directly challenges the central premise of Big Health and the local health system — that community-based health models that require the skills, knowledge and cultural competency of refugees would outperform by miles the high tech, highly trained, and very expensive professionals. But as progressive leaders realize, both a community-based model and a centralized system are necessary.
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| 1000 Skilled Physicians, disconnected from refugees, immigrants and the poor |
In Greensboro and surrounding region what we have is an empowered system unwilling to make any but the most minimal concessions and token gestures. After the Great Recession few in middle management are willing to risk further cuts to personnel, equipment and resources. Any new ideas from new workers endangers whatever department heads and survivors have managed to save, including jobs. While other metropolitan regions in the state are climbing out of the Great Recession, Greensboro remains retarded, hobbled by conservative leaders and scared workers. This is why I believe the regional discussion about health for refugees, immigrants and the poor has never been a rational one.
