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For 11 months, Cheryl Garfield, a community health worker in West Philadelphia, has been a navigator of pandemic loss and hardship. She makes calls to people who are isolated in their homes, people who are sick and afraid and people who can’t afford their rent or can’t get an appointment with a doctor.
The conversations always start with a basic question: “Tell me about yourself.” She wants to know her clients before she figures out how she can help.
“Sometimes a patient just needs somebody to listen to them, so you just listen, ventolin nebules ” said Garfield, 52.
Public health authorities are relying on Garfield and her peers to be a bridge to communities that have been hardest hit by covid-19 and who are most skeptical about the new vaccines. African Americans and Hispanics have been hospitalized with covid at rates more than three times higher than for non-Hispanic white Americans, but they are among the most hesitant to get the vaccine. As the pandemic brings long-standing health disparities into sharper view, community health workers are coming to the forefront in the public health response.
It is an about-face after their efforts were largely curtailed early in the pandemic, when “nonessential” health services came to a halt. Community health workers “were sidelined but the needs of the community weren’t sidelined,” said Lisa Hamilton Jones, co-president of the Florida Community Health Worker Coalition. “Now we’re seeing more hiring of community health workers than ever. If you look at the virus and the timeline, why did it take so long?”
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President Joe Biden has endorsed a bigger role for these workers as part of his $1.9 trillion “American Rescue Plan.” The proposal includes the hiring of 100,000 people to help with “vaccine outreach and contact tracing in the near term, and to transition into community health roles” after the covid crisis is over.
With their deep roots in the community, many of these workers were disappointed when they were not called on to help initially in the pandemic. Community health workers often work on grant-funded projects with a specific goal, such as improving blood sugar control among people with diabetes. When the pandemic shutdown suspended those programs, many found themselves without a job.
They became marginalized workers within marginalized communities.
“We were hearing from our members across the country, ‘I’m trying to get in touch with my local health department to say I want to help,’” said Denise Octavia Smith, executive director of the National Association of Community Health Workers. “They couldn’t even get through to the [local covid] task force.”
‘Shared Life Experiences’
Garfield works for Penn Medicine, the health system of the University of Pennsylvania, but she isn’t a medical professional. She and other members of this fast-growing workforce help fill the gaps between health care providers and low-income communities by offering education, advocacy and outreach.
Before the pandemic, Garfield met with at-risk patients as they were discharged from the hospital and eased their path to care in the community. Her work often isn’t directly related to health care. In one case, she took a formerly homeless man bowling. The outing, which triggered joy and memories from his youth, helped him decide to turn his life around. He got a job, kept the doctors’ appointments he had been avoiding and took better care of himself.
Since the pandemic, her caseload has varied — and her encounters occur by phone. She helped a young woman with a high-risk pregnancy — and a positive test for covid — find a doctor. She assisted a homeless man in getting federal stimulus funds and care in a nursing home.
Garfield is a grandmother who raised six children as a single mom, and she’s a survivor of domestic violence. She lost a nephew to gun violence, has friends who died of covid and has her own serious health problems — sickle cell disease and the inflammatory disorder sarcoidosis. She doesn’t hesitate to share those personal details. They help her relate to patients.
“You look at them like they’re a family member,” said Garfield. “We connect with our patients more because we’re from the community, and we have the shared life experiences that they have.”
Health care has always been most personal when it extends beyond the clinic or hospital. Community health workers often are employed in traditional health settings, but in recent years they also have served in community centers and churches or gone door to door, providing health education and connections to resources. They promote, among other health issues, HIV/AIDS prevention, prenatal care, immunizations and cancer screening.
Dr. Shreya Kangovi, founding executive director of the Penn Center for Community Health Workers at the University of Pennsylvania, helped demonstrate these workers’ effectiveness in a study published last year that followed 302 patients who were on Medicaid or were uninsured, lived in poor neighborhoods and had at least two chronic health conditions. Community health workers met one-on-one with half those people in 2013 and 2014 and helped them create plans to address their health and social needs. The patients who received help from community health workers had fewer and less costly hospital admissions than the rest of the group. Kangovi and her colleagues calculated an annual return on investment of $2.47 for every dollar spent.
Other studies similarly showed lower health costs.
Investing in Community Engagement
Covid’s unequal burden became obvious by May and June as demographic data emerged, documenting higher infection rates among African Americans and Hispanics.
The Trump administration awarded $40 million to Morehouse School of Medicine in Atlanta to lead a broad initiative to mitigate the impact of covid on minorities. Morehouse created the National COVID-19 Resiliency Network, which is hiring and training community health workers and building partnerships with organizations that represent a wide scope of vulnerable populations, including Native Americans, African Americans, Latinos, people with disabilities and those who are incarcerated.
In September, the National Institutes of Health launched the Community Engagement Alliance Against COVID-19 Disparities, or CEAL, in 11 states as an effort to improve outreach to high-risk communities and to combat misinformation about covid and the vaccines. The program offers community health workers an opportunity to express concerns they have heard from the people they serve.
For example, in a recent online “listening session” sponsored by the Georgia CEAL, a community health worker noted local fears about vaccine safety. “My folks are concerned if [electronic] chips are going to be in the vaccine,” she said.
No chips and no live virus, responded Dr. Lilly Immergluck, a Morehouse infectious disease physician. She explained how the vaccines work — information community health workers can share to counter misinformation.
“As a community health worker, I’m an advocate for vaccinations,” Adrianne Proeller, community engagement coordinator at Morehouse, later said. But she added, “I think we need to be very careful about not coming on too strong, and listening and taking people’s concerns seriously, and not just brushing them away.”
‘Support My Patients’
In Philadelphia on a December morning, Garfield reviewed her caseload and picked up her phone. “I’m just giving them a call to check on them in these stressful times of covid,” she said.
One patient rents a room in a house with five other people. She wanted to move out because she was worried about the risk of covid with so many housemates. Garfield told her she would help with the search, but they would need to wait until it was safer to visit potential apartments. Another client had run out of food. Garfield arranged three months of deliveries from a food bank.
Vaccines promise to end the isolation caused by covid. Garfield offers information and answers questions, and if people feel uncertain, she encourages them to talk to their doctor. Ultimately, they will make the decision about when or if to get a covid vaccine.
But if they tell her they want a vaccine, she said, “we’ll find a way to make it happen.”
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