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.