Consider this proposal to address firefighting disparities:
“The problem of fires in resource poor areas is growing. Even though we’ve had the tools to control fire for years—namely water, buckets, and hoses—thousands of people and millions of valuables continue to burn each year. Unfortunately, the employment of professional fire fighters in rural areas has not proven to be sustainable. Since we know that resource poor communities are primarily affected, we believe we should use mostly local, culturally appropriate methods to address this issue. Therefore, we propose the creation of a cadre of fire health workers. With only 5 days of training on essential fire topics, such as flammable materials and effective stamping out methods, they will be a cost effective work force ready to take the problem of fire into their own hands. Although fire protection suits and salaries are beyond the reach of local budgets, luckily, water and pails are readily available in most communities. Fire health workers will be on call 24 hours a day, 7 days a week, to attend to either small fires (i.e. grease fires in local kitchens) or larger fires (i.e. forest fires). We believe that fire health workers will give up part of their livelihood to volunteer their time, as they understand the severity of this issue and its effect on their safety. This way, we will have an equitable distribution of services across all areas and populations.”
To some, this proposal might make some sense, but to the vast majority it will sound completely illogical. It is a specious argument, indeed; we know that a paltry collection of poorly trained community members in resource poor areas will never be able to control a forest fire—the vision is hideous, terrifying, and only exacerbated by the lack of adequate training, funding, equipment, or back-up support for serious challenges. Why is it that when we substitute “fire” for “illness,” the ridiculous qualities of this proposal somehow seem to disappear, and the vision is no longer terrifying? This, at least, has characterised the rationale for community health worker programmes for decades. Ever since the WHO conference at Alma-Ata in 1978, where delegates from every representative nation signed an agreement to work toward “health for all,” the idea of the community health worker has oscillated between being a cutting edge method, to empowering marginalised communities to being considered a “false start.”[i] Health policy towards these health workers, unfortunately, has often taken the form of our proposed fire workers: a marginally trained, minimally supported, band of impoverished volunteers who are expected to do alone what the rest of us couldn’t, i.e. bring health to all.
Moral philosophy informs these thoughts. Kant argued that we should “act to treat humanity, whether yourself or another, as an end-in-itself and never as a means,” suggesting that the current employment and improper management of community health workers is not only ineffective, but also unethical. Rawls’ principles of justice, especially if we accept the strategy of “maximin,” similarly remind us of the logic behind providing the most for those who have the least. This principle should extend to community health workers, who often begin with so little but of whom so much is expected. In fact, a double indemnity of ethics is at play here: we abuse not only the health worker, but also the patient when the healthcare option we provide them during their illness is sub-par.
Community health workers have proven that they can change health outcomes. [ii]-[iii] But, for them to be effective, and for patients to reap the full benefit of their labors, they need to be trained in a manner appropriate to their experiences—compensated for their labor in a way that aligns incentives with outcomes, equips them to do the task at hand, and connects them to powerful systems of back-up support proportionate to the challenges being addressed. They must be seen as an important part of a larger chain of services that produces value for the most needy patients and improves health statistics in a concerted way. Failures are not the fault of the community health workers but of the health systems that do not properly incorporate them.
A few steps must now be taken to ensure a synergistic relationship among communtiy health workers and existing health systems in the delivery of patient care. First, the training of community health workers has all too often been simply inadequate and poorly conceived. As one once related to me, “we’re trained with words that only doctors understand, expected to do what doctors don’t want to do, and then blamed like peasants when we fail.” Our studies with community health worker trainings have suggested that they need innovative, simplified yet authoritative, lessons that value what they already know, but make clear what they are expected to learn. [iv] Many come from communities that are skilled in manual labor, which often teaches through example and hands-on practice. It is as if we have been asking them to learn how to ride a bike from pamphlets without ever providing them with a bicycle.
After making clear what they are expected to know, they must be adequately equipped. The equipment should be intuitive to use, and its uses should be clearly delineated. This equipment need not be over simplified; indeed, with the rapid adoption of mobile devices in many poor communities, even barely literate community members are incredibly adept at using the most universal personal computer—the cell phone. In our own project site in Guatemala, we are piloting a cell phone program that allows community health workers easy and immediate access to accurate medicine doses for common easily treated but potentially fatal diseases in children. A pilot study suggests that they prefer the interactive format over similar paper resources. [v] The function of this tool, of course, demands that the they also have access to basic medicines (depending on local laws and customs), for without a medicine supply chain, any such cell phone will become simply a toy gadget instead of a life-saving medical device.
Yet, even if community health workers are knowledgeable, well equipped, and do their job effectively, many health systems are still afraid to pay them. Perhaps the fear is that they will unionize and demand more pay—a benefits package or maybe paid vacations? However, if they are, in fact, employed to carry out a task, should they not be compensated? Though perhaps initially daunting, the payment scheme does not have to become a black hole of unaccountable salaried workers; indeed, it is possible to match incentives to outputs such that they may have the dignity of a paid job while also working towards measurable outcomes. In some community health worker projects, they are not paid but given access to credit, food, cooperative membership, or goods they can re-sell. Such a system may prove to be more sustainable than cash payment, but care must be taken to ensure that this does not become a slippery slope leading to a perception of community health work as a mere commodity. It is also possible that a pay-for-performance model might work better; because they are usually selected by their communities in public forums, this same public mechanism can help to ensure accountability. At this point it is unclear which system of compensation will ultimately be the most effective—irrefutable, however, is that unpaid workers simply don’t, or can’t, work well. [vi]
Finally, even when community health workers are incentivised to work, they cannot work alone. If only to appear legitimate before their patients, they need to have referral options available for when the disease they are treating extends beyond their abilities and the tools at their disposal. In fact, leaving someone stranded with a sick patient is arguably the single most effective way to destroy their desire to continue working. Ambulances, consultations from visiting doctors, and referral hospitals with surgeons on call comprise only a part of an adequate support network. In addition to these material support networks, they need to know that the rich world is serious about improving the health of the poor. This can only be demonstrated by pragmatic actions made manifest through functioning systems and sustained funding.
Small community health worker programs with all the elements I discuss here are known to work. Larger national programs often lack these. I suspect this is why they tend to fail. Failure, then, would not be due to a deficiency in the concept, but rather to the failure to give the scaled-up programme the necessary human and physical resources it needs to succeed. Let’s inform our ethics with our biology. The poor are made of flesh, as are we—the readers of this periodical in the rich world. Diseases respect neither borders, nationalities nor class; if we stand with the poor and the community health workers who treat them, we will thrive with them. Looking around, I see a world that is on fire. Epidemic disease blazes through the houses of the poor world, and flames lick at the walls of the rich. If, instead of improving upon the programs of which community health workers are a part, we rather choose to abandon them, then we too may one day find ourselves sick. Is there any ethical issue more pressing than that of global health?
[i] Berman, Peter A., Gwatkin, Davidson R., and Burger, Susan E. “Community-Based Health Workers: Head Start or False Start Towards Health For All?” Soc Sci Med 25 (1987): 443-59.
[ii] Haines, Andy, et al. “Achieving child survival goals: potential contribution of community health workers,” Lancet 369 (2007): 2121–31.
[iii] Mitnick, Carole, et al. “Community-Based Therapy for Multidrug-Resistant Tuberculosis in Lima, Peru,” New England Journal of Medicine 348;2 (2003): 119-128
[iv] Lightfoot, Michelle, Niconchuck, Jonathan, and Palazuelos, Daniel. “Evaluating the effectiveness of a community health worker training curriculum in rural Guatemala,” (2010): Unpublished, in early manuscript.
[v] Palazuelos, Daniel, Palazuelos, Lindsay B. “Assessment of a Mobile Medicine Dosing Reference Software for Community Health Workers (CHWs),” (2010): Unpublished, in progress.
[vi] Walt, Gilt. “CHWs: are national programmes in crisis?” Health Policy and Planning 3;1 (1988): 1-21
Daniel Palazuelos is an associate physician at the Brigham and Women’s Hospital, and an instructor of medicine at Harvard Medical School. He is the clinical director of the Partners In Health-supported projects in Chiapas, Mexico and Guatemala. Partners In Health is a US-based NGO working to bring advanced medical care to the world’s sickest and poorest people. In this role, he lives for half of the year in isolated communities in the Sierra Madre Mountains, training local community health promoters, providing medical care, conducting research, hosting medical student projects, and creating original curricula. For the other half of the year, he lives in Boston and practices inpatient medicine with the hospitalist group at the Brigham.
Competing interests: DP does pro-bono work for Partners for Health, a Boston-based NGO and they assist him with travel support to work abroad.