Chapter 2: Shattering the Glass Floor

Matthew 25:31-46

pm508summer2014:

This week in PM 508 “Healthcare Delivery in the US”, we discussed the current problems and benefits safety-net providers face with the implementation of the Affordable Care Act as well as the topic of the shortage of primary care providers in the United States.  I wanted to use my past three home-visit trips comment on one member of the primary team that I have fundamental to cost-effective, effective and comprehensive patient care: community health workers.

The below posts are of my trips with Community Health Representatives (CHRs) with the Navajo Nation.  I share about my experiences with them in those posts, where overall I found them to be hidden heroes in the delivery of effective primary care for patients with chronic illness on the reservation.  

Now take a second to look at some pictures that were taken on our home-visits with the vector (mosquito) control team of the Ministry of Health just outside of District 24, Panama.  On this trip we went out with two promatoras, which is the name given to Latino CHRs. What do you see?  How do these pictures differ from my pictures from the Navajo CHR trip?  Although promatoras for Panamanian vector control and Navajo CHRs for chronic illness will be different due to the innate difference between vector control and chronic illness, since both are claimed as CHRs, some key comparisons can be made.  Lets start with:

Picture 1: Notice the patient speaking to the team behind their iron fence.  While some families did offer us a seat to sit down with them, most just talked to us outside the home while standing.  In contrast, at the Navajo Nation, we were always invited to sit down in their living rooms.

Picture 2: Notice the differing dress of the man (without shirt) we talked with and one of the vector control staff members.  Although along one street there were some families that were more well off, with tiled floors indoors, and others like this older gentleman who were not, the difference in physical appearance between this family and the vector staff was noticeable.  While we administered a community needs assessment survey, the promatora walked around their home with a black marker to draw on containers or even their house wall with an “X” for any open water source found.  If these warnings were not addressed within thirty minutes, the families would be fined $100.  

3) Picture 3: Whenever you see a picture, to understand the context and people in the picture, it is important to also remember that someone was standing in the scene taking the picture.  In this case, a vector control staff took this picture.  While I appreciate that he took this picture and others like it with my camera for our team’s records, I could not help but be uncomfortable with the preceding actions of walking into the home while our team and the mother were conducting a survey, standing behind this mother and snapping a picture from inside her home.  Notice that I have zero pictures of the homes and individuals that I visited on the Navajo Reservation.  Then ask why the difference?

Picture 4 & 5: A vial of mosquito larva found in coconut shells at a house and the little critters in the staff’s hand.
Do not get me wrong.  I support the vector control teams efforts to ensure that mosquito breeding grounds are aggressively identified and resolved before large out breaks of dengue occur with high mortality rates and hemorrhagic fever.  The need is there, as exhibited by the larvae we found for mosquito Aedes egypti which have the potential to spread a deadly disease.  The invasive home visits and fines are necessary, because even if all but one home in a community cleans their home, that one home can breed mosquitoes that can infect the entire community.  

However, I question whether the promatores CHR model fits with this vector control team.  Although very nice ladies, the nature of their work and their authoritative and punative relationship with the community undermined their ability to identify with the community.  Likewise, my pictures show that the community does not seem to relate or identify with the vector team well either.  The relationship is vertical, instead of horizontal, which is the basis of the CHR identity.  

One consequence of this difference exhibited through these pictures, is that I will be writing a policy brief asking the district government to create policy and funding channels to keep promatoras distinct from the Ministry of Health.  One solution is the formation of neighborhood health councils with local promatoras who operate separate from the vector control team.  My USC MPH vector control team conducted a community assessment and found this approach to hold the most potential to changing source-reduction behaviors in the community.

Relating this to the US Primary Care System, this lesson illustrates that the type of profession can become irrelevant if the method, vision and goals are not also correct.  CHRs housed under an authoritative and punitive vector control system, cease being CHRs.  Likewise, our primary care problems cannot only be solved by adding more primary care doctors, mid-level providers or others, but new systems of organization and funding under Patient Centered Medical Homes must be created in parallel to ensure that these new providers can be what they were meant to be.  

On Friday July 18th in the Crownpoint Service Unit of the Navajo Nation, 7 Community Health Representatives, trained Certified Nurse Assistants who make home visits and improve their community’s health and capacity, came together for a focus-group I conducted on a Brain Health train-the-trainer module I have been developing with Partners In Health for the past half year.  The module will contain descriptive, symptom, treatment, prevention and caregiver support information for patients with brain conditions such as Alzheimers, Parkinsons, stroke and even migraines and seizures.  Using powerpoint, the printed product will be bound so that it can be used as a flip book, with pictures on one side for the patients and text on the other side for the CHRs.  I’ve developed it using National association and UpToDate as my sources, but am conducting these feedback sessions to ensure that the content, format, and cultural literacy is relevant and effective for the CHRs to use in helping families on the Navajo Reservation.  Above was the team of 7 CHRs at Crownpoint who provided amazing advice!   

I know they will never see this blog, but they are unsung heros in their communities and serve without the praise that doctors are often blindly given.  Thank you very much Crownpoint CHR team!  It was a pleasure working with you all!

As some of you know, I am part of a church plant that will be launching in almost three months!  As Re-Create Church prepares to begin on October 5th, we are first serving the community by offering a series of free classes with lunch that address key issues of life with licensed or credentialed instructors.


Lunch is provided, RSVP on our Facebook page (preferred).
Instructors: 
Dr. Liang-Ying Chou, licensed marriage and family 
therapist, assistant professor & Dr. Kay “Yoko” Tanaka, licensed clinical psychologist, associate professor in

clinical psychology.

Location for all classes
PopRock Academy
11 S. 2nd St, Alhambra, CA 91801
Sunday, June 22 & 29, 12:00 pm – 2:00 pm
Free Parking


Community Classes by Re-Create Church are intended to serve the needs of our community, bringing in experts of their fields to address matters that can positively affect people’s lives.  Classes are entirely free and lunch is provided.  Your RSVP is very much welcomed to help us efficiently plan for each class, but is not required. Please contact us with questions or your RSVP. This is one of the ways Re-Create desires to bless its community.
As some of you know, I am part of a church plant that will be launching in almost three months!  As Re-Create Church prepares to begin on October 5th, we are first serving the community by offering a series of free classes with lunch that address key issues of life with licensed or credentialed instructors.
Instructors: 
Dr. Liang-Ying Chou, licensed marriage and family 
therapist, assistant professor & Dr. Kay “Yoko” Tanaka, licensed clinical psychologist, associate professor in
clinical psychology.
Location for all classes
PopRock Academy
11 S. 2nd St, Alhambra, CA 91801
Sunday, June 22 & 29, 12:00 pm – 2:00 pm
Free Parking
Community Classes by Re-Create Church are intended to serve the needs of our community, bringing in experts of their fields to address matters that can positively affect people’s lives.  Classes are entirely free and lunch is provided.  Your RSVP is very much welcomed to help us efficiently plan for each class, but is not required. Please contact us with questions or your RSVP. This is one of the ways Re-Create desires to bless its community.

A little video I threw together of the first day of my Masters of Public Health practicum trip to Panama:  The Panama Canal

From Market to Freezer: The Tradition of the New Mexico Hatch Green Chile Pepper:

Buy, Grill, Peal, Dice, Bag and Freeze.  Simple, fun, and the best way to make your whole home smell delicious!  The local secret to this process is to wear gloves, because the chile oil in these peppers can literally burn your hands!  And now I have peppers for the rest of the year!  Or maybe just for a week…

So I’m playing catch up trying to post all my pictures still from New Mexico!  Above are pictures from my day of home visits on the reservation with Community Health Representative Irene Harley.  This time I drove 2.5 hours North from Gallup at 5:45am to meet Irene at Huerfano Chapter in the Ship Rock Service Unit of Navajo Nation.  That day we went to visit four patients.  Irene had such a lightness and joy to her that it felt like she wasn’t affected by the gravity of her work.  We checked on patients with colds and another with suspected Parkinsons.  On our way back, she told me that she has been a CHR for 30 years!  And with nine years prior working at the Chapter House, serving her community, Irene has dedicated herself to the health and well-being of her community for 39 years straight!  That explains the lightness she gives off when doing her work. 

Our last visit was to a lady Irene worked with to help her build a new home!  This was a patient Irene worked with for a long time, but even with her health managed, her patient fell into a slump.  Irene worked with her week after week, trying to convince her to apply for a housing grant and pick herself back up.  With persistence, the woman gave into Irene’s loving pleas.  She applied for the 1 grant in per Chapter house for a new home and got it!  In addition to that, Irene walked up to one of the key construction workers in town and told him he had to help her patient build her home for her with the grant she obtained.  And with a tangibly simple task of helping her patient build a new house, her patient was able to stand again and be herself again!  Even though she wasn’t home when we arrived, I found myself walking up to a beautifully simple 5 year hold home with a fresh white paint and a nice little garden.  Walking up to that house and hearing Irene’s story of working with this woman, blessed me with that same joy and lightness Irene so beautifully embodied.  

Above are some pictures of Irene’s CHR car that they are provided to make home visits with.  The Health Center sign below that is of the nearest emergency medical center that serves this community.  It was at this health center, that Irene helped helicopter a stroke patient to when she diagnosed his distress on the field some 15 miles away.  The blue and white building is the Huerfano Chapter house that serves as the community center for the community with offices for all local services like Irene’s CHR office.  And lastly, is a picture of Irene and I in front of their CHR event calendar.  

BBQ’d, pealed, chopped, bagged, frozen for the year!  6 pounds of New Mexico hatch green chile peppers!

The Veterans Affairs Wait-List Scandal: A Symptom of a Broken National Primary Care System ~ Warren Yamashita

pm508summer2014:

Sitting here at The Coffee House in Gallup, New Mexico, a small Southwest town with a population of 20,000, it is not to hard to turn the corner and bump into veterans everywhere you go. In fact, many Navajo Indians here have served in the Korean and Vietnam wars. This is a proud American town…

July 11th, 2014

From my little weekend excursions, many know that I am New Mexico right now, but I haven’t yet explained what brought me back this summer.  From my volunteer experience at the Missionaries of Charities’ Soup Kitchen and Homeless Shelter in Gallup, New Mexico, a year and a half ago, I navigated through the small-town “two degrees” of separation to find that Partners In Health (PIH) was working the the Navajo Nation, Indian Health Services and the Community Health Representatives (CHR) program to support and help maximize potential that CHRs offer in improving community health and increasing its capacity resilience. (http://www.pih.org/blog/cope-brings-cross-pollination-to-navajo-nation)

CHRs are usually Certified Nurse Assistants who are native to the communities they serve.  They serve as an extension to the clinic and hospital healthcare systems and prove to be invaluable in crossing the linguistic and cultural barriers that prevent providers from meeting the health goals of their patients.  Not only do they provide medical check-ups, education, counseling, instruction and social support, but they also go the extra step in connecting patients to necessary resources and providing them referrals.  I’ve met CHRs here who helped their patients collect firewood to make sure they literally would not freeze during winter and another who helped her patient receive a new house, which served to revitalize her whole person.  

My work with PIH involves developing a training module and flip book for the CHRs on the topic of “Brain Health”, which will cover topics like Parkinson’s Disease, Alzheimers, stroke, migraines and seizures as well as caregiver topics on burnout, preventing injury, stages of dementia, etc.  Last Spring, I put together a draft module, right before I started my neuro system of medical school!  Since then I’ve been improving the module draft by draft, but last Friday I worked with a group of 7 CHRs from the Fort Defiance Service Unit of the Navajo Nation to elicit feedback from the professionals!  Over a two hour straight feedback session with some group activities to keep us all awake, I came out with a weeks worth of feedback to integrate into the module!  These CHRs were a great group of participants and provided the right mix of serious advice as well as humor to make it a perfect session.  This week I am working to integrate their feedback in preparation for one more feedback session this Friday in the Crownpoint Service Unit.

Spidy Rock! Canyon De Chelly, AZ

Why USC CCTC?: A new Kaiser survey about the need for more insurance educators

Today the New York Times published an article titled “Groups Under Health Act Are Said to Aid Millions: Assisters Helped 10.6 Million With Coverage Under A.C.A.”, in which they described the results of a…

Why USC CCTC?: A new Kaiser survey about the need for more insurance educators

Today the New York Times published an article titled “Groups Under Health Act Are Said to Aid Millions: Assisters Helped 10.6 Million With Coverage Under A.C.A.”, in which they described the results of a…

Why the Myers-Briggs test is totally meaningless

Good article, although I suspect there is some evidence for a degree of validity for the test.  ie) If 50% of individuals score differently a set period of time, then 50% actually continue to score the same. <—that is a degree of validity.  The article itself uses a lack of references to justify its own arguments but rather uses anecdotal and statements of assumption to prove its point.  So although I don’t think the Myers-Briggs test is really meaningless, I do agree with the authors argument that it lacks evidence that merits its wide range of applications and it definitely should not be earning the company over 25 million dollars in profits per year!

That being said, I’ve scored INTJ consistently 6 years ago and within this last year.  However, being an INTJ sucks, for according to Myers-Briggs interpretations, we are one of the rarest personality type (1-2%) and tend to be the most independent/isolative personality type of all 16.  :(

Canyon Duche, AZ with ancient Anasazi pueblo cliff-side homes from ~300AD.

Yesterday I visited, Canyon De Chelly near Chinle Arizona.  At 10 different lookout points, you can see ancient ruins from the Anasazi indians, aka “Ancient ones” from ~300AD!  It was an incredible site to see these homes hundred of feet in the air constructed by these ancient pueblo.  The Anasazi Indians were the ancestors of the Hoppi and Navajo Tribes.  Just looking over this beautiful canyon  and imagining the river that once flowed down there with farms and pastures along the bank was like looking back in time more than 2000 years ago.  

Spider Rock, Canyon De Chelly, AZ