AMA Journal of Ethics^®

Abstract

ESP

This first-person narrative examines life-changing effects that community health workers (CHWs) have on the well-being of marginalized community members and illuminates Chicago, Illinois’ HealthConnect One as an example of a new health care organization needed to promote equity. CHWs offer culturally informed health services that are healing and transformative, and their work promotes health practice reforms that motivate equity through incremental and steady change. CHWs’ work also underscores the need for clinicians and organizations to respond to deeply entrenched, long-standing patterns of oppression in ways that draw upon data and lived experience to support and advance linguistically and culturally proficient service delivery in Latinx communities and in all marginalized communities.

Need for New Health Service Delivery Models

In January 2021, we faced the unfathomable knowledge that every 26 seconds, someone was dying from COVID in America.¹ Yet Latino and Black Americans and American Indian/Alaska Natives have COVID-19 death rates at least 2 times higher than those of White and Asian Americans.² This pandemic has magnified the neglect and health disparities in communities of color and has made inequity and institutional racism in our health care system glaringly evident. The data tell an irrefutable story of damaging, avoidable health disparities in communities of color. It is time to consider different health care options and modalities to best meet the diverse needs of our people.

This essay examines the life-changing effect that community health workers (CHWs) have on the health and well-being of marginalized communities by providing culturally informed care that is healing, transformative, and essential for their clients. My own personal experience as a client and as a CHW brings attention to the need for change in social practices and policies that are systemic, subtle, and cumulative and that result in oppression and health inequity.

Community Health Work

The American Public Health Association defines a community health worker (CHW) as “a frontline public health worker who is a trusted member of and/or has an unusually close understanding of the community served.”³ CHWs promote health within a community by assisting individuals to adopt healthy behaviors. They advocate for individual health needs by facilitating effective communication with social aid agencies. They also implement programs that educate clients and promote, maintain, and improve individual and community health. They work in communities, either as part of medical teams in hospitals or providing in-home care as necessary. CHWs typically promote breastfeeding and child nutrition, family planning, immunization, and other behaviors linked to maternal and child health. They also promote awareness about social welfare issues, such as domestic violence or alcohol and drug abuse. CHWs may also provide preventive services such as blood pressure, glaucoma, and hearing screenings.

Most importantly, CHWs are a cost-effective and culturally and community-informed option for providing health care support. They are less expensive than visiting nurses and social workers and provide critical preventative care. Studies show that CHW doula care provides cost savings among Medicaid recipients by reducing cesarean births⁴—which cost 50% more than vaginal births⁵—and by reducing the use of epidural analgesia⁶ and its associated costs. Doula care thus leads to reduced costs in instrument-assisted births and repeat cesarean births, as well as to improvements in initiation of breast feeding, safe sleep practices, and early implementation of car seats.⁶ Moreover, if 90% of mothers in the United States followed breastfeeding recommendations, $13.8 billion annually could be saved in pediatric health costs and preventing premature deaths.⁷ We know that healthier families lead to healthier communities.

For all these reasons, CHWs are key to development and implementation of positive community partnerships and actions that undo the effects of years of racism, discrimination, neglect, and avoidable health inequities (see Figure). CHWs understand the needs of communities of color, which is paramount to successful and cost-efficient interventions.

Figure. Descriptions of Community Health Workers in Latinx Communities

© Wandy D. Hernandez-Gordon. Courtesy of HealthConnect One.

It is important for CHWs to understand that the more than 60 million Latinos in the United States⁸ represent a diverse community whose members have unique backgrounds, cultures, beliefs, and challenges—especially challenges in accessing health care. Sadly, Latinos are nearly 3 times more likely to be uninsured than non-Hispanic Whites.⁹ At this time of great need, job loss, and economic recession, many are unemployed and without employer-provided health insurance. Today, nearly a third of Latinos ages 5 and older are not fluent in English,¹⁰ creating yet another barrier to adequate health care. Health professionals with cultural and language proficiency are critical to successful interventions, including health education, preventative medicine, and treatment. But these interventions are only the start in addressing the higher burdens and challenges that Latinos face in accessing quality health care. It is also critical to dissect and understand the systems and structures that both lead to and exacerbate health inequities.

Lived Experience of Obstacles

I know firsthand the challenges that Latinos face in obtaining health care. Now a practicing CHW, I had very humble beginnings. My teenage parents were unable to care for me, so my grandparents, who were servant leaders in Puerto Rico, raised me with love. They believed that true leaders served the needs of their communities. I hold this belief close to my heart to this day. My grandmother was a community midwife and mortician. She assisted “mi gente,” my people, at the beginning and end of life. The socioeconomic deprivation that I witness within my family and community make me passionate about community health.

My mother struggled with mental illness, and my childhood did not include playing with my friends, jumping rope, or playing hopscotch, but it was rich in knowledge and love. As an 8-year-old girl, shadowing my grandparents who were CHWs and helping them ensure that community members had proper health care and social services and that their concerns were heard by hospital and clinic professionals, I lived the community health model. While other children played with their friends, I knew I had to make sure that I helped a community member get her medication from the local pharmacy. I learned many lifelong lessons as I accompanied elders to the public aid office to help translate and fill out their forms.

CHW’s personal and professional experiences enable us to understand unmet basic needs in Latino communities.

To this day, I struggle with the memory of experiencing racism for the first time. A social aid worker quickly transformed into a monster when she realized my grandparents didn’t speak English. Her response was hurtful. Clearly annoyed, she snapped, “You should know the language, we are supporting your island.” I was a child and felt shocked, numb, and unable to process this cruelty. No child—or any human being, for that matter—should have to experience such ugliness head-on. It is still hard for me to understand the lack of humanity flung at my grandparents at the public aid office. But the real dilemma for society is that these types of interactions prevent people from receiving the health care they need.

This experience led me to educate myself about the application process and build the relationships needed to advocate for, and to help our community gain access to, public aid and health care. Clearly, when seeking medical attention, we all need trust, understanding, accurate information, reassurance, and kindness, along with cultural and language sensitivity. These are basic necessities that help increase access to care and motivate equity. CHWs are the key to restoring equity in low-income communities and communities of color. In particular, doulas are the key to providing much-needed pre- and postnatal support, as health care continues to suffer during this pandemic and period of economic downturn and joblessness.

Experience as a CHW

Like many other CHWs, my life has had many ups and downs that led to my life’s work. Those hard lessons that inspire and inform our work make us passionate about being effective CHWs for the community. When I was forced to live with my birth mother, she subjected me to physical and emotional abuse, which made me stronger. Much like the clients I serve today, I became a teen mom and experienced challenges. My upbringing helped me focus on how I could help others in similar situations. My experiences serve as a reminder to always temper my health care knowledge with empathy and patience so that I can adapt to the needs of the communities I work with.

My grandparents, aunts, and friends taught me how to be a mother. My relationships in the maternal health field, including with midwives, nurses, and health care workers, became an invaluable support system. The Latino community protected me, educated me, and spurred my passion for health care in marginalized communities. Because of the community help I received, my 2 grown children enjoyed their youth, broke the teen pregnancy cycle, and have many beautiful memories to share with their own children.

CHWs led me to enroll in a lactation program at a bilingual, bicultural organization. This 10-week breastfeeding training, which included work as a breastfeeding peer counselor and using my daughter as a model, changed my life. Later, I worked at the same center, educating and supporting pregnant women and new mothers about breastfeeding. Again, I used my daughter as a live model. This work led me to get my high school diploma, continue my studies, and ultimately to pursue a CHW career. Now a CHW, I use the unique skills that I developed as a child and adolescent in my community, coupled with my schooling, to assist my clients and their families. I became a community-based doula, thanks to the HealthConnect One 20-week training course.

Community health changed my life, both as a recipient and as a giver of culturally sensitive care that is based on respect and love. My trajectory exemplifies how CHWs can develop critical skills by living in the communities they are vested in serving. It also shows how invaluable CHWs are in combating implicit bias, racism, and stereotyping that interfere with the quality of care for communities of color. We are in the community and have ourselves experienced implicit bias, racism, and stereotyping in our work and lives. Our critical insight into shared challenges and shared trauma that we bring to the work we do is invaluable in building trust and helping to solve the health care challenges facing the communities we work in.

For most CHWs, addressing the challenges in our community is personal, and CHWs are uniquely qualified and effective in this work. Our personal and professional experiences enable us to understand the unmet basic needs in Latino communities. We are also vested in the local, regional, and national constituents interested in developing equitable grassroots programs to support the CHW profession.

A New Kind of Health Care Organization

HealthConnect One is one example of an organization with a history of working in, for, and with communities to address inequities that Black and Brown people continue to face. The Illinois Community Health Workers Association (ILCHWA), formerly known as the Chicago CHW Local Network, was created by health educator professionals to support, facilitate, and advocate to enhance the CHW workforce. I was the co-founder and vice president of ILCHWA because I am committed to combating the inequities that CHWs face in the health care workforce, and I continue to maintain a vital role in the organization today.

Health organizations that espouse equity and health justice—not just in their vision statement, but also in their day-to-day operations—are much needed. Growing the CHW profession will increase individuals’ access to reliable health information, provide them with linguistic and culturally sensitive care, and improve health outcomes for all, regardless of socioeconomic status, background, or identity.