'On The Frontline Of Injustice': Community Health Workers Could Improve How Long And Well You Live
About a decade ago, Shreya Kangovi and colleagues at the University of Pennsylvania interviewed 1,500 people in Philadelphia on porches, at hospital bedsides, and in shelters — people who were living in high-poverty communities. All the people interviewed were asked one question: What makes it hard for you to stay healthy?
“Patients told us, for example … that health care providers were constantly setting them up to fail because we give people goals that are not realistic,” said Kangovi, an associate professor of medicine at Penn and a leading national expert on the use of community health workers to improve population health.
“We say, ‘Mr. Jones, you need to take your Lasix,” Kangovi said. “Well, [Mr. Jones] needs to keep his job as a bus driver, and he can’t stop to pee every 30 minutes.”
Kangovi and her team used those interviews to develop IMPaCT, a standardized, scalable program that leverages community health workers — trusted lay people from local communities — to improve health. IMPaCT has been delivered to over 10,000 high-risk patients in the Philadelphia region.
And in the last three years, it has become the most widely disseminated community health worker program in the United States, having been replicated by organizations across 18 different states, including the Veterans Health Administration, state Medicaid programs, and integrated health care organizations.
Kangovi said she thinks of community health workers as a bridge between communities and health systems and other systems of care. Unlike other kinds of health care professionals who are strictly defined by licensure and degrees, community health workers share life experience with the people they serve and often have leadership roles within the community, so they can leverage trust in unique ways.
Typically, community health workers are paired with people in high-poverty neighborhoods who are battling a confluence of health and social inequities, from housing insecurity to high blood pressure.
“We are not actually in the midst of a novel pandemic of coronavirus,” Kangovi said. “But rather what we’re seeing is actually just a manifestation of a pandemic that’s been going on for a much longer time, and that is the pandemic of injustice.”
Despite overall improvements in population health, Kangovi said, health disparities like cardiovascular disease have persisted over time, particularly in marginalized communities of color.
There is about a 20-year gap in life expectancy between the richest Americans and the poorest Americans.
But the primary focus of physicians has been to address risk factors for disease such as smoking or diabetes. And the same has been true of the COVID-19 response in Black, Asian, and Latino American communities, where the death rate is disproportionately higher than that of white Americans.
“What we are calling risk factors are just, in fact, intervening mechanisms,” Kangovi said. “And actually the cause of disease is the underlying socioeconomic conditions.”
Local and federal policies such as immigration and labor laws, neighborhood and domestic exposure to violence, air, and water pollution — these all set the stage for certain groups to have a disproportionate burden of disease.
Kangovi said unlike doctors who focus on treating health outcomes such as diabetes or hypertension on the downstream of injustice, community health workers can intervene at all stages because they share life experience of discrimination and disadvantage with those they serve.
‘Let me find out how I can help myself and others’
At 13, Nahar Alam was forced into an arranged marriage in her birth country of Bangladesh. Alam married a local police officer, and he quickly became physically abusive. Looking for a way out, she fled to the United States in 1993 and found work as a caretaker.
“I came to this country to survive,” recalled Alam. “ But then I worked as a babysitter, and I found so much abuse there which is not reported.”
Settling in Brooklyn, New York, where she had no family to depend on and little English proficiency, she would soon encounter another form of abuse in the homes of her employers. Exhausted and overworked from 12-hour-plus shifts, Alam said she would make as little as $75 a week. And it was common to be denied time off. She even recalls her employers socially isolating her and workers like her by denying them access to the phone.
“And then I thought, let me find out how I can help myself and others,” Alam said.
Stressed by those working conditions, three years later she became a volunteer for Sakhi for South Asian Women, a nonprofit domestic-violence prevention organization. There, she connected with other South Asian immigrant women working as caretakers, cooks, and cleaners in domestic settings who were also experiencing a spectrum of workplace abuses.
“There was nobody to listen to us,” Alam said. “We started the program just to talk to each other, listen to each other, and [do] outreach for each other.”
The women found power in their shared experiences, and together they worked to promote fair working conditions and minimum wage and labor standards, and organized demonstrations outside the homes of exploitative employers. Then in 1998, Alam founded her own organization,
Andolan — one of the first domestic workers’ groups to emerge in New York. Composed of a handful of South Asian domestic workers, Alam and her team helped women through lawsuits against abusive employers and linked them to a range of city services. In 2010, in collaboration with a local labor network called Domestic Workers United, they fought for better working protections and ushered in the first Domestic Workers Bill of Rights.
Alam’s self-advocacy turned into powerful community advocacy. Now, she’s the program associate at the Diabetes Research, Education and Action for Minorities Initiative (DREAM), a community health worker intervention that addresses the burden of cardiovascular disease in New York City’s Bangladeshi community.
“If you hear ‘organizer,’ ‘housekeeper,’ ‘babysitter,’ or ‘community advocate,’ that’s the same [thing] as a community health worker,” Alam said. The same way I advocated for people [then] is the same way I’m doing it now in the health care system.”
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