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Consider this proposal to address firefighting disparities:<\/p>\nConsider this proposal to address firefighting disparities:<\/p>\n
\u201cThe problem of fires in resource poor areas is growing.\u00a0Even though we\u2019ve had the tools to control fire for years\u2014namely water, buckets, and hoses\u2014thousands of people and millions of valuables continue to burn each year.\u00a0Unfortunately, the employment of professional fire fighters in rural areas has not proven to be sustainable.\u00a0Since 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.\u00a0Fire 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.\u201d<\/p>\n
To some, this proposal might make some sense, but to the vast majority it will sound completely illogical.\u00a0It 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\u2014the 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 \u201cfire\u201d for \u201cillness,\u201d the ridiculous qualities of this proposal somehow seem to disappear, and the vision is no longer terrifying?\u00a0This, at least, has characterised the rationale for community health worker programmes for decades.\u00a0Ever since the WHO conference at Alma-Ata in 1978, where delegates from every representative nation signed an agreement to work toward \u201chealth for all,\u201d the idea of the\u00a0community health worker\u00a0has oscillated between being a cutting edge method, to empowering marginalised communities to being considered a \u201cfalse start.\u201d[i]\u00a0 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\u2019t, i.e. bring health to all.\u00a0<\/p>\n
Moral philosophy informs these thoughts. Kant argued that we should \u201cact to treat humanity, whether yourself or another, as an end-in-itself and never as a means,\u201d suggesting that the current employment and improper management of community health workers is not only ineffective, but also unethical. Rawls\u2019 principles of justice, especially if we accept the strategy of \u201cmaximin,\u201d 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.<\/p>\n
Community health workers have proven that they can change health outcomes. [ii]-[iii] But, for\u00a0them 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\u2014compensated 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.<\/p>\n
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.\u00a0 First, the training of community health workers has all too often been simply inadequate and poorly conceived.\u00a0As one once related to me, \u201cwe\u2019re trained with words that only doctors understand, expected to do what doctors don\u2019t want to do, and then blamed like peasants when we fail.\u201d\u00a0 Our studies with\u00a0community health worker\u00a0trainings 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.\u00a0It is as if we have been asking\u00a0them to learn how to ride a bike from pamphlets without ever providing them with a bicycle.\u00a0<\/p>\n
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After making clear what\u00a0they are expected to know,\u00a0they must be adequately equipped.\u00a0The equipment should be intuitive to use, and its uses should be clearly delineated.\u00a0This 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\u2014the cell phone.\u00a0 In our own project site in Guatemala, we are piloting a cell phone program that allows\u00a0community health workers\u00a0easy and immediate access to accurate medicine doses for common easily treated but potentially fatal diseases in children.\u00a0 A pilot study suggests that\u00a0they prefer the interactive format over similar paper resources. [v]\u00a0 The function of this tool, of course, demands that the\u00a0they 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.<\/p>\n
Yet, even if\u00a0community health workers\u00a0are 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\u2014a benefits package or maybe paid vacations?\u00a0 However, if they are, in fact, employed to carry out a task, should they not be compensated?\u00a0 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\u00a0they may have the dignity of a paid job while also working towards measurable outcomes.\u00a0In some\u00a0community health worker\u00a0projects,\u00a0they 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.\u00a0It is also possible that a pay-for-performance model might work better; because\u00a0they 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\u2014irrefutable, however, is that unpaid workers simply don\u2019t, or can’t, work well. [vi]<\/p>\n
Finally, even when\u00a0community health workers\u00a0are incentivised to work, they cannot work alone. If only to appear legitimate before their patients,\u00a0they need to have referral options available for when the disease they are treating extends beyond their abilities and the tools at their disposal.\u00a0In fact, leaving someone stranded with a sick patient is arguably the single most effective way to destroy their desire to continue working.\u00a0Ambulances, consultations from visiting doctors, and referral hospitals with surgeons on call comprise only a part of an adequate support network.\u00a0In addition to these material support networks,\u00a0they need to know that the rich world is serious about improving the health of the poor.\u00a0This can only be demonstrated by pragmatic actions made manifest through functioning systems and sustained funding.\u00a0<\/p>\n
Small\u00a0community health worker\u00a0programs 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.\u00a0Failure, 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.\u00a0Let\u2019s inform our ethics with our biology. The poor are made of flesh, as are we\u2014the 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.\u00a0 Looking around, I see a world that is on fire.\u00a0 Epidemic disease blazes through the houses of the poor world, and flames lick at the walls of the rich.\u00a0 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.\u00a0 Is there any ethical issue more pressing than that of global health?<\/p>\n
[i] Berman, Peter A., Gwatkin, Davidson R., and Burger, Susan E. \u201cCommunity-Based Health Workers: Head Start or False Start Towards Health For All?\u201d\u00a0 Soc Sci Med 25 (1987): 443-59<\/a>.<\/p>\n [ii] Haines, Andy, et al. \u201cAchieving child survival goals: potential contribution of community health workers,\u201d Lancet 369 (2007): 2121\u201331.<\/a><\/p>\n