tackle other issues related to poverty and inadequate housing, they are not necessarily hybrids, she noted.

Dr. Bracho also discussed issues related to community workers. Community workers live in the community and get paid to transform their communities, but they know that financing is needed for their community to improve. Now they are starting to be managed by members of academia and are receiving certification from people who know nothing about the communities that the workers represent. In this way, community workers are recognized as community leaders with implied credibility; yet, she asked, what type of community worker are they? How does one train and sustain them? In situations like this, the communities and the hybrid model are being forgotten.

Ms. Gottlieb responded that community health aides in Alaska are trained at the community level. The health aides are tribal people who receive training over a 6-month period, and they are often the only trained medical professionals in the entire village. That means that they are the doctor and the behaviorist. They provide all of the medical care in the community, and this system is working. It is simply impossible to provide a physician for $200,000 a year or more to every village.

Dr. Bracho countered that she would like to know what else is being done to rectify situations like the one in which Gottlieb’s family used to live. What are you doing in your community to address issues like teen pregnancy or alcoholism? How are your health care strategies connected to the rest of the communities’ efforts to follow a hybrid model, and how much are you doing to initiate change?

Ms. Gottlieb responded by discussing how funds are allocated in Alaska. Although there must be accountability, she said, she would still advocate for bulk funding, down to the level of those directly providing services. In receiving funds for providing a health care system, there must be accountability to the constituents who use those services. This means that funding would be allocated for community health workers if providing for these workers has been identified as a priority by the community.


IOM (Institute of Medicine). 2001. Crossing the quality chasm: A new health system for the 21st century. Washington, DC: National Academy Press.

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