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Health Worker Roles in Community Orientec! Primary Care John Hatch and Eager~ia Egg Forces of change industrialization, urbanization, and rising expectations constantly demand modification and adjustment in organizations and insti- tutions that serve people. Displaced peasants throughout the world are moving to urban centers in search of a better life, while those who remain on the land pray for the relief they believe modern civilization can bring. Black tenant farmers in North Carolina, after years of struggle, belatedly joined the industrial revolution as textile workers and occupied the noisiest and dirtiest jobs. Former subsistence farmers in the United Republic of Cameroon, who have chosen to grow tobacco as a cash crop, were en- couraged to seek new land and focus all of their efforts on tobacco. These changes have caused severe disruption of traditional patterns of living, which include the lack of access to schools, health services, and support systems of small town or village life. Few regions on earth are immune to these forces. Even when the changes are perceived as being progressive, the potential for creating a less responsive social and economic system is great. COMMUNITY INVOLVEMENT IN COPC Failure to involve community people in planned change will, at best, limit the potential for service, and, at worst, result in social disorganization and lead to gross compromise in the quality of life. There is evidence that our ability to tolerate stressors within the broader environment is related to the quality of relationships and the degree of social support we receive from those who are closest to US.~-5 Therefore, is it reasonable to believe 138

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Health Worker Roles 139 that significant advance health can be achieved without the involvement of community people and without attention paid tO the patterns of relation- ships between and among those who are members of the community? Planners in societies structured as differently as the Peoples' Republic of China and our own have come tO realize the limitations of traditional responses to the challenges of rapid change in an increasingly interdepen- dent world. Activists and planners with skills in community organization have followed the direction of redefining traditional roles and relationships. Barefoot doctors, cholera control agents, outreach workers, nurse practi- tioners, sanitation aides, health educators, and many many others are per- forming roles as old and new as man himself. Their fucntions are to be responsive to human needs, and as needs change so will their roles. Health status is more an indicator and a symptom of inequality than its cause. We agree with Dr. Sidney Kark that "changes in the environment, standards of education, and social status as determined by occupation, ed- ucation, and income exert greater influence than does the medical care system on favorable mortality and morbidity trends, as well as on improve- ments in health."6 If we as professionals committed to the practice of community oriented primary care (COPC) agree with these statements, then what exactly is the charge of the COPC health team? And more specifically, what is expected of community health workers? Perhaps it would be best tO begin with some widely held assumptions that tend to impede development of COPC. Given these assumptions, we will then attempt tO bring life and immediacy tO these questions by attaching real people, events, and time to the evolution of the COPC health worker role in America. We will draw on earlier experiments, for we believe, as.Iohn Grant did, that health care should be a social service that must be provided within the context of other basic social services.7 We can learn from the observation that the many transactions that have taken place thus far be- tween communities and professionals have not yet fulfilled this vision. A review of several initial COPC efforts may clarify our concern that com- munity involvement in human service planning and administation remains conceptually incomplete. SOME FALSE ASSUMPTIONS Impeding the full development of COPC or any other community oriented human service that is externally supported and controlled are three very basic, yet false assumptions. The first assumption is that the commmunities' priorities, norms, and values are sufficiently similar to those of the profes- sional so as to provide a mutually rational framework for peer cooperative action. The reality is that there have always been discrepancies between

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140 PART I: THEORETICAL ISSUES the intentions of providers and the needs of consumers. This conclusion is borne out by case study after case study of programs theoretically well conceived that fail.8 The second false assumption is the belief that social diagnostic tools are sufficiently well developed to provide the outsider professional with an inside view. Household surveys, attitude, scales, interview schedules, eth- nographic studies, locus of control, health belief models, and so on are sometimes necessary but never enough for understanding how a community of people operates, survives, and feels. These tools are certainly not the solution for erasing the discrepancies between the intentions of profes- sionals and the needs of communities. The final assumption that impedes full development of COPC and makes planning and administration conceptually incomplete is that professionals have little to learn but a good deal to teach. Little recognition has been given by the professional community tO the uniqueness of community knowledge, skills, expertise, and experience for all aspects of program plan- ning and implementation. The lack of dialogue between outsiders and in- siders is not due to the community's lack of having something to say. It is due to the difficulty in communication, both semantic and emotional, ex- perienced by insiders and outsiders alike. Also, outsiders too frequently forget why they need to involve communities when faced with the im- mediacy of clinical intervention. Kark and Abramson strongly support community involvement as an in- tegral component of COPC so that certain key questions can be answered: How do communities function? What are their networks? What is the formal and informal leadership? What are the activities of day-to-day living? What is the family and kinship structure? Community health workers are seen as vital members of the COPC team in answering: "What is the state of the community's health?"; "What factors are responsible for this state?"; "What is being done about community health itself and by the services available?"; and "What are the community's perceptions and expectations about services and about promoting itS own health care?" The answers to all these questions are crucial pieces for community involvement in program planning and implementation, but we must not lose sight of why we need these answers. It is not because we need to develop more effective persuasion tactics to increase health service utili- zation delivered through a preconceived plan. It is not because community health workers are to act as a one-way mirror through which the COPC team reflects to the community what they have to offer. Rather, we need the answers to these questions to help a COPC program strengthen the abilities of a community tO influence itS own development, especially when the community is removed from the mainstream. This may mean throwing

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Health Worker Roles 141 preconceived, professional, and scientific notions of what is effective health care delivery out the window. Although community needs and priorities will rarely fit neatly into the health service delivery model, they will mesh very closely with community development strategies. Fortunately, the two approaches need not be mutually exclusive if we believe that community development has a greater influence than medical care on improvements in health status. COPC workers need not feel torn, for they are the link in the middle. The authors of this paper, because of ethnicity on the one hand and education on the other, see themselves as occupying a middle-person role with loyalties and roots in both the community of professional peers and of ethnic brothers and sisters. We choose the term "middle" rather than the more commonly used concept of"marginality," as we feel the former more accurately conveys our sense of place within this spectrum. In our case, the feeling of belonging to either in terms of an ordered state of being is equally strong. John Hatch, the first author, has his initial professional degree in social work. The message transmitted through that educational experience as he perceived it was that members of his ethnic group were a problem to themselves and, consequently, placed limits on personal development. The logical continuation of this line of thought was that he, too, might be a problem. However, these notions were counterbalanced by his awareness that the expert commentators on the status and mental state of his ethnic group were not black. Later, while working as a community organizer for the South End Settlement in Boston, he met scholars from MIT, Boston University, Harvard, and other academic institutions in the region. He knew that the professors from these universities were interested in understanding how communities worked. He was not, however, aware at the time of the power of theoreticians in developing social policy and in influencing strat- r egles tor active intervention. Several years after these contacts, Hatch discovered that several papers, as well as books, written by two of these professors and their students were being cited by urban renewal and social planning officers as providing deep insight into the functioning of Roxbury and the South End communities of Boston. He took issue with those portions of their research considered to be inaccurate or distorted. It was explained to him that he was too close to the problem to offer an objective assessment. Although he was assured that the scholars respected his ability as an implementer, Hatch was en- couraged to entrust overall conceptualization to those who had been trained to think objectively and in abstract terms, since they were the ones best able to identify those options most likely to have a positive impact on future generations.

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42 PART I: THEORETICAL ISSUES Reliance on this research resulted in a decision, which was later reversed, by the Boston Redevelopment Authority, to eliminate store front churches from the communities. It has been reasoned that these churches exploited the poor, prevented or compromised the ability of their congregations tO focus on the real problems they faced, and were noisy and unsightly. An- other researcher "discovered" that pimps were bright, had a strong self- image, and tended toward action. These findings led to a decision to recruit pimps as staff for community improvement programs. When placed in positions of sanctioned authority, they, of course, proceeded to replicate in the community the type of relationship they had previously established with their women. The sentiments and motivations that led to these outrageous violations of judgment and common sense were quite probably well intentioned. Indeed, there were very serious problems that warranted radical action. However, the missing element in these and many other situations was not only the shortage of technical skill needed to define community for the perspective of the community's own sense of identity and priorities, but also the recognition that there was another perspective. During the course of preparing this paper, we were informed of the death of one of the most effective community organizers in America over the past half century. Amzie Moore, janitor, lead singer for the Delta Har- moneers, deacon, civil rights worker, civic leader, and good neighbor died in Cleveland, Mississippi. In 1965 Mr. Moore was president of the Bolivar County Chapter of the Central Development Group of Mississippi, an organization correctly perceived by state powers to be somewhat political. In those days evaluation was used as a tool of control. As part of a site visit to assess the quality of citizen participation in the local Head Start Program, a meeting of community supporters, which included Mr. Moore, was held at the Bright Star Baptist Church. The government senior evaluator, who was a university professor, and his staff attended the meeting with Hatch. Later, in discussing the meeting the senior evaluator complained that Moore did not address the audience in terms that made any sense and that the entire evening appeared closer to the rites he associated with exorcism than with a discussion on the impact made by citizen involvement on the pro- gram. However, after listening to Hatch's perceptions of the Bright Star Church meeting, and checking with another trusted person, the evaluator came to a better understanding of the meeting and could report more accurately to the funding agency. During this period, Hatch was involved in collecting ethnographic data to be used in planning the Tufts-Delta Health Center in Mound Bayou, Mississippi. Returning twice monthly to Boston, he was debriefed in ses- sions held with Donald Kennedy, a medical anthropologist with the Tufts Medical School, Department of Preventive Medicine. This experience was

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Health Worker Roles 143 invaluable in raising Hatch's awareness of cultural bias and assumptions. He discovered that there were many important conceptual constructs es- sential to the daily lives of seasonal workers and tenant farmers that phy- sicians and social scientists did not know existed. We as credentialed workers are still in the process of discovering, but only if we are willing to listen and learn. We are poorer today because of our failure to collect and learn from the wisdom of individuals like Amzie Moore. He had found the way to nurture and inspire thousands of oppressed people toward redefining their role in society. We know so little about the process he used. This is not to say that there has not been any successful program in health care and other human services that achieved a high degree of sensitivity in itS relationship with the people it served. Over the past two decades, we have known a number of movers and shakers in health care and other fields. We are not sure of the characteristics that go into the making of successful activists and community workers, but it is certain that they did not acquire their motivation and skill in professional schools. These individuals can be found among credentialed and uncredentialed persons. The credentialed include people trained as nurses, sanitarians, physicians, social workers, economists, lawyers, clergymen, public health workers, political scientists, and horticulturists. Others involved with activism and community devel- opment in health care include maids, laborers, farmers, fishermen, con- struction workers, coal miners, pulpwood cutters, and others representing a fair sampling of occupational groups in the United States. Of course, we have a few hunches about the qualities that enable some individuals to rise above others and inspire community action. Eugenia Eng is currently en- gaged in research that examines characteristics that enable community lead- ers tO lead. Which qualities are generic and which ones are culture-specific? Can they be defined in terms of selection criteria for recruiting community health workers? Can they be enhanced through a training program? EXAMPLES OF COMMUNITY INVOLVEMENT IN COPC In an effort to better understand the role COPC workers should play in the formulation of community action strategies leading to improved health status, we will review two models of community and professional interaction that produced, in our estimation, good results. It is hoped that the examples will lead COPC toward identifying those principles that seem to contribute most significantly to the favorable outcomes experienced. South End Settlement Between the years of 1940-1960, Boston witnessed a sixfold increase in the number of black people in its population. When Hatch arrived in that

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144 PART I: THEORETICAL ISSUES city in 1958, the "service crisis" caused by the influx of"newcomers" was a permanent agenda item for board and staff conferees sponsored by health and human services agencies serving inner-city communities. The newcom- ers frequently delayed requests for services to the point of compromising the effectiveness and efficiency of delivery. For example, parents often failed to produce immunization and birth records when they were re- quested. Boston professionals, and particularly those providing services to the communities experiencing increased migration, had difficulty under- standing the great differences between the norms, values, and functioning of the newcomers and those of the older established black families in their neighborhoods. Some had hypothesized that perhaps the older established blacks had come from superior stock and were, therefore, better able to adjust to the rigors of survival in the competitive New England environ- ment. It was reasoned that the older established blacks had recognized the value of northern migration two or three generations earlier and had not required intensive agency support for adapting to northern urban patterns of living. Newcomer families, on the other hand, were not stable. It seemed that newly arrived black males were especially vulnerable to the temptations of urban life. Many developed drinking problems and left their families for street life. Their children experienced learning difficulties in school. They appeared to have problems with understanding spoken English and were themselves unable to communicate clearly with their teachers or the children of older established blacks. Newcomer children tended to be greatly ov- errepresented in special classes for slow learners and the developmentally . . 1mpa]LreC L. In 1962 the South End Settlement, which was a Boston-based multi- service organization, was faced with the dilemma of an increase in the demand for services that was greater than its budget could tolerate. In an attempt to deal with this situation, the agency agreed to support Hatch, who was a community organizer trained in social work and a newcomer himself, to mobilize community members to work as front-line workers for the organization. Prior to this time, possession of a bachelor's degree had been a prerequisite for employment with the Settlement House. Some professional` employees extended warnings that declining quality of service and loss of trust would be the probable outcome of this experiment. None- theless, being the community organizer responsible for this effort, Hatch knew that most of the problems encountered by newcomer families were being managed within the network of community resources. He felt that reinforcement of this system by the Settlement House would be more effective and efficient than hiring two or three recent college graduates. Hatch's knowledge of community-helping networks was gained in large measure through his experience of living at Mrs. Bailey's rooming house

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Health Worker Roles 145 on Columbus Avenue and being included into her social system. Mrs. Bailey seemed tO know everybody for blocks around. She was an active church woman, a member of the Sisters of the Eastern Star, and a former domestic worker for several of Boston's influential families. She was active in her block organization, fed alcoholics, and had conversations with the street ladies who marketed their services from the corner nearest her house. In addition to providing immaculately maintained living quarters, Mrs. Bailey's roomers were given generous portions of wise advice on urban survival, even though she would come forward with formidable support when failure to heed her advice landed one in difficulty. On various occasions Hatch had observed her negotiate a suspension of sentence for one of her roomers who had been picked up in a corner dice game, provide counsel in lovers' quarrels, place people in jobs, advise police on how best to intervene in cases of domestic conflict, and confer with human service agencies before deciding to refer her people to them. Hatch would sometimes accompany Mrs. Bailey to special events and would be introduced as "one of her boys." Her network spanned the spectrum of urban life-styles, and she appeared sure of herself within each segment of her complex set of social relations. Proud of her origins in rural western Tennessee, Mrs. Baily maintained active linkages with friends and family still living there and often acted as a sponsor and advocate for those who came to Boston in search of work. She felt that lack of decency, trust, and respect were the major barriers to achieving a good community and did her best to make this world a better place. In discussing the development of the new Settlement House project with Mrs. Bailey, Hatch received valuable guidance and was assured of her support. The five people hired as half-time workers for the project were members of large community networks and fulfilled roles as advisers, counselors, and linkers to the elaborate social system. Miss Troupe was a retired beautician and had lived in Boston since taking a summer job there 40 years earlier. Reverend Willie was the pastor of the storefront-housed Lily of the Valley Holy Church. He, his wife, and five children lived above the church. Rev- erend Willie supplemented his income from the church by renting rooms in his home and working as a handyman. He had lived in the South Carolina low country prior to moving north to join his brother, who worked at the Navy Yard. Miss Holly was a retired nurses' aide from Children's Hospital and had remained active as an adviser on child health and social problems to the community, linking people to an astounding array of professional and neighborhood support services. She wrote letters for persons who felt insecure dealing with bureaucracies to obtain the necessary documents for employment or for admitting children into the Boston school system. Ad- ditionally, Miss Holly knew each person offering informal home child care and held strong opinions and accurate information on the different levels

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146 PART I: THEORETICAL ISSUES of quality. The fifth worker was Miss Connie, who at that time was employed as a part-time domestic, but had traveled the nation as a dancer. She had settled down in her middle years, but maintained ties with persons of the night life and entertainment world. She would not take jobs that required reporting for work before 10:00 a.m., for she felt that the best part of the day was the night, and she wanted to enjoy at least a part of the best. Orientation for the team of community front-line workers was carried out in a seminar format, focusing on the Settlement House's history, phi- losophy, and minimum standards for record keeping and employee ac- countability. Completing case records was a collaborative effort in which Hatch guided the interviews in accordance with standard case work pro- tocol, recorded them on tape, and summarized the content for the agency's permanent files. In retrospect, the relationship between the Settlement House and the community workers could be construed as being somewhat exploitive, be- cause they worked more hours than they were paid for and were available during evenings and weekends. However, they did seem to appreciate the recognition and especially the title of Social Outreach Workers. Each of them carried an active case load larger than any one carried by the agency's professional workers. During his 3 years of working with them, neither Hatch nor the agency had received complaints from a client. There were, however, points of conflict with professionals from other health and human service organizations. Miss Connie had used strong language with the social worker at the Travelers' Aid Society when, during the course of discussing a case, the social worker had said that the society would do all it could to send the colored girls back where they belonged. Miss Troupe had caused a minor incident by forcing her way into a child custody hearing to defend the right of a sometime, part-time prostitute to maintain custody of her children on the grounds that this woman was a good mother. She had asked the ad- judicators if any of them had ever violated the legally prescribed norms of sexual behavior and added her opinion that, if they had not, then she felt sorry for them. Another conflict occurred when Reverend Willie had man- aged to have a basketball court paved but had neglected to gain approval from the city before negotiating with cement truck drivers to dump their surplus at the site. The Settlement House had been working with the city's Department of Parks and Recreation for quite some time to carry out this task, but shortage of funds was continually given as a reason for why it could not be done. The team of Social Outreach Workers survived these and other conflicts with the established health and human service delivery system. As a result of this process, the known pool of resources had been vastly expanded,

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Health Worker Roles 147 and the latter agency had gained respect and trust from the community due to its association with the Social Outreach Workers. Hatch met with them on a weekly basis to discuss and assess the course of their work. In time they began to observe certain patterns. Young women who had entered the city as domestics with no support from friends or family comprised a disproportionate percentage of the agency's case load. These women were being exploited by some of the employment agencies that had recruited them from the South, by their employers at times, and finally by streetwise males on the women's days off. As evidence for these patterns became stronger, the Social Outreach Workers felt that they should act to prevent these occurrences rather than continually react to the crisis. The agency community organizer wondered quietly how a young social worker, a holiness preacher, and four middle-aged and older women could possibly make a dent in an activity highly valued by persons with vested interests in prostitution and the drug trade. Miss Connie suggested going to the suburban bus terminal on Thursdays from 10:00 a.m. to 4:00 p.m. to talk to women getting off the bus who looked like maids coming to the city for weekends off from work in the suburbs. Lack of anything to do in the evening was identified as a major problem for these women. The Social Outreach Workers also discovered that pimps, pushers, and hustlers were also meeting the buses. The four women and Reverend Willie met with each of the employment agencies tO inform them of the situation. Miss Troupe set aside a room in her house and identified other people who were able to offer shelter to maids on their days off. More importantly, it was anticipated that the renters of rooms would also provide advice and counselling to these newcomer women. The selection of these renters was made with this expectation explicitly stated. Within 6 months the NAACP, local women's organizations, other health and human service agencies, storefront churches, and fundamentalist evan- gelical churches joined a planning group to consider the needs of single women migrating to Boston to work as domestics. The up-front, no-non- sense character of the Social Outreach Workers enabled them to cut through bureaucratic protocol and objections that could have been barriers for a professional. The NAACP representative, for example, intially questioned the merits of an effort aimed at improving the status of domestic workers rather than providing them with assistance to find other occupations. Miss Holly responded by reminding him that his mother had been a maid when he was a boy, and that if she were still alive, she would want him to use his education to improve conditions instead of criticizing. After 18 months the program received funding from the United Fund and the Department of Labor. A service aimed at upgrading the skills of domestic workers was staffed by Mrs. Bailey and several wealthy women

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148 PART I THEORETICAL ISSUES who had formerly been her employers. Posttraining salaries were, on the average, 50 percent higher, and all domestic employment was covered by contracts specifying duties, obligations, and responsibilities. The program continues to operate under the sponsorship of the League of Black Women and has a Board of Directors that is broadly representative of the inner- city communities. This group was eventually able to lobby the Massachusetts state legislature to pass regulations protecting domestic workers. Willingness and conviction to upset the status quo through unorthodox means of interventioncussing sometimes, praying other times are nec- essary for transcending barriers that separate people from their rights to services. To whittle down the barriers means establishing a double flow of communications going up-down and down-up by developing interactions and rapport such as that described between the Social Outreach Workers and the professional social worker who coordinated their efforts. Their intricate and unique knowledge of their community, coupled with a degree of honesty from professionals who felt uncomfortable with Miss Connie's statement of "Who in the hell gave you the right to determine where black women should live?" was much more effective in helping an agency identify an appropriate intervention than a professional conference on perspectives would have ever been. MOUND BAYOU Our second example of meaningful interaction between communities and professionals occurred in 1965, when the Department of Preventive Med- icine of the Tufts University School of Medicine gained support from the Office of Economic Opportunity tO develop a health center in Bolivar County, Mississippia site 1,400 miles from its home base in Boston. In addition to responding to the desperate needs of the citizens in this county, it was felt that a health center in Mississippi would provide professionals with insights into the social norms, values, health attitudes, beliefs, and behaviors of a population that was becoming increasingly important to health and human service agencies working with the inner-city districts of Roxbury, South End, and Columbia Point. It was also felt at that time that the nation had at least decided that all of itS citizens were entitled tO health care. Believing that national health care coverage would surely come within the decade, energies were shifted from advocacy focusing on the passage of legislation tO the search for a health care model that would improve the health status of the population as well as be responsive to the legitimate demands of communities. Each of the three individuals primarily responsible for the design of the Mound Bayou model brought with them prior ex- periences that would strongly influence the structure of that project.

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156 PART I: THEORETICAL ISSUES was for Eng to find out when the director had scheduled a visit to the Gad jagan dispensary, and the village chief would be sure to be present on that day. The reasoning behind this particular choice of action was that they wanted the nurse to be replaced but not fired, for they believed him to be a basically decent man with a drinking problem, and they wanted to be sure that the authorities understood the problem to be manageable if appropriately mon- itored. Writing letters was not felt to be an effective means for achieving these objectives, nor was it a method of communication with which they felt comfortable. Interpersonal interaction was, and so the leader of the community would speak with the leader of professionals. The director arrived as scheduled and inspected the clinic records and facilities, making note of the low-utilization rate and paucity of drugs and equipment. A message was sent that the village chief wished to greet him in his home. It was there that the problem was introduced and discussed fully. Within a month the nurse was transferred to a dispensary outside of the region and replaced by another who was just as unenthusiastic about outreach, but did not have a drinking problem. Over the course of the next 3 years, while Eng was still working in Togo, the director of maternal and child health services always asked about the people of Gad jagan whenever he saw her. The experience for him was as meaningful as it was for the community, because it linked him to and demystified the world of the villagers to some degree. By combining their own wisdom and priorities with new knowledge about the provider system, the people of Gad jagan sharpened their ability to function as partners with professionals in problem resolution. Their rep- ertoire of legitimate choices was expanded, and they gained more confi- dence about what they already know and do. By arranging the meeting between the director and their traditional village leader, the community was actively involved in the entire process of conflict resolution with the health care system. The health workers did not intervene on the commu- nity's behalf by either writing letters for them or going directly to the director to present him with the problem to arrive at a solution about input from those who are experiencing it. The act of linking the community to available resources became one of enablement enabling it to experience a sense of influence and control over its own community's welfare and development. COPC workers can and must fulfill a third role, that of enabler, by facil- itating community action in which the worker does not take the lead, but is there to support community initiative and momentum. Choices, potential obstacles, and possible consequences are the contributions of an enabler. The final decision and commitment to work toward it must come, however,

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\ Health Worker Roles 157 from the community. There is a difference between working "on behalf of,' and "at the behest of." Who has the most vested interest in effecting change? Who is more effective in persuading policymakers, decision makers, and other officials to respond than the ones who are not being treated equitably? By mobilizing community resources, COPC workers can make a significant contribution to community development. Leadership and, most certainly, the desire for a more satisfactory quality of life exist within any community. COPC workers need to be trained in community organization skills to be able to identify and strengthen indigenous leadership to meet that desire by developing strategies with them as peers. Reducing barriers to health care may be a first step in the enabling process, but it definitely is not the final one. In conclusion, we see the challenge for COPC workers as that of being able to: . translate the perspective of communities and of professionals to each other; . link communities to the resources available from professionals, as well as link professionals to the strengths and ingenuity of communities; and . enable communities to take full advantage of the resources and knowl- edge for initiating community action. If the vision of COPC is to increase the abilities of poor and near-poor people to influence their own community development, then are COPC workers ready tO extend their arena into social and political action? If COPC truly believes that changes in the environment, standards of education, and social status have a greater effect than the medical care system on health improvements, then are COPC workers ready tO go beyond the use of biostatistics, clinical epidemiology, and biomedical services for defining the problem? As we stated in the beginning of this paper, poor health status is an indicator and a symptom of inequality, not its cause. Will COPC continue to treat the symptom and not the cause? There is a wealth of knowledge, experience, and skills for dealing more effectively with the causes of health status. COPC has been unable to draw upon and use this knowledge to date. It is out there with the communities in which we work and with the ones we want to involve in program planning and implementation. At times we recognize it but do not know what to do with it. At times we look for it but do not see it. And then there are the times when we both see it and use it and a true partnership begins. COPC workers and supporters have all had some experience with a meaningful relationship between communities and themselves. We shared some of ours in an attempt to identify those principles that seemed to contribute to

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158 PART I: THEORETICAL ISSUES favorable outcomes and to offer more reasons for why COPC is the hope for neglected communities. REFERENCES 1. Cassell, John (1974) An Epidemiological Perspective on the Psychosocial Factors in Disease Etiology. Am. /. Public Health 64(November): 11. 2. lames, Sherman, and Kleinbaum, David (1976) Socioecologic Stress and Hy- pertension Related Mortality Rates in North Carolina. Am. ]. Pablic Health 66(April):4. 3. DuBois, Renee, and.Tackson, Barbara Ward (1972) Only One Earth: The Care and Maintenance of a Small Planet. Norton: New York. 4. Geiger, H. Tack (1969) Health Center in Mississippi. Hosp. Pract. 4(February):68. 5. Hatch, John (1978) Self-Help and Consumer Participation in the Development of the Health Care System. Ann. N.Y. A cad. Sci. 310(June 21). 6. Kark, Sidney (1981) Practice of Commanity-Oriented Primary Health Care. New York: Appleton-Century-Crofts. 7. Seipp, Conrade (1963) Health Care for the Community: Selected Papers of John Grant. Baltimore: Johns Hopkins Press. 8. Paul, Benjamin (1955) Health, Culture, and Community. New York: Russell Sage Foundation. Discussants Richard Smith I have been, and continue to be, critical of primary health care (PHC) or community oriented primary care (COPC) as it iS characterized by hundreds of demonstration or pilot projects scattered around the world, limited in scope and funds, and predominantly serving the needs of the sponsoring institutions and donor agencies that carry them out. The wreckages of increasing numbers of these small projects are strewn across the landscape of scores of countries. And along with these projects are the imagery and reputation and future of PHC. Confidence in PHC as a viable entity is being eroded at the local village level by the combination of unbridled zeal to do something~nythingon one hand, and the inability tO follow through with successful programs and resources scaled up to meaningful levels, on the other. Much of this is being described with a "diarrhetoric" that talks of success as if we already know how to provide PHC to the majority of populations. Such is far from the truth. And such are my fears for COPC

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Health Worker Roles 159 in this country, along with economic crunch, that is going to stall progress . . ln tn1S arena. I would like to take this brief time to talk about two related issues: (1) community involvement in primary care and (2) the roles of nonphysician providers of primary care services. Health services in developed countries like the United States are rigid and resistant to change entrenched and tracked with organized medicine, institutions of education, and technology development. They seem resistent to change when compared tO emerging health systems in the less indus- trialized world. In the Third World, the movement in health is to get out from under the often inappropriate, irrelevant, resource-consuming yoke of the Western medical mode. And there is much for those of us in de- veloped countries to learn from the Third World, as many developing countries are opting for primary health care as a guiding force. PHC overseas is defined with much more community involvement in the health system. It is seriously concerned with other sectors that impinge on health and vice versa. We can take safe water supplies and solid waste disposal almost for granted in our country; 80 percent of the world cannot. Health and well-being for most of the world has to be concerned with such things as: food production, preparation, preservation, and storage; immu- nization against common preventable diseases; income generation from cottage industries; oral rehydration of children before they defecate them- selves to death; transportation and marketing of goods; and curative care of common health problems. These are but a few of the components of PHC as viewed in the Third World. But they are the guts of COPC or PHC in those nations and have to actively involve the community, since limited resources mean that for the most part they have to be self-sufficient. However, as John Hatch describes it, we still talk here in the United States of PHC as a "top-down" laying on of hands, doing things in the community for the community, to the community, and less so with the community. The message coming out of Professor Hatch's paper that needs reiteration is that the American community has something to contribute tO its well- being in this scheme we call COPC. The message coming out of the de- veloping country experience is the same. The economic dilemmas we face now in health care are going tO worsen. As they do, the poor and the minorities and the elderly will suffer more. The communities many of us work with will be changing in character. Middle America will have to face the same biting winds of change, with pain familiar to many of us. The present health system in our country is weighted heavily towards technology, services, and resources instead of needs It will have tO respond tO the present call for reform in a way different from the marketplace predictions. I think we will see opportunities for

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160 PART I: THEORETICAL ISSUES COPC increasing I repeat- the opportunities will increase. However, I am an idealist and have no illusions that the American people want to take advantage of these opportunities and read history; so frequently they seem only to want to write it. The history I am talking about reading refers to the efforts that have been made to identify the character of"working-together behavior," dem- onstrating that health professionals can and will work on a large scale with people in their communities who are prepared to assume their rightful role in responsibility for their own well-being. It is an investment behavior that is different when one is part of a truly COPC program, one characterized by responsibilities that "bubble up" as well as "trickle down." The history I am talking about is the experience with extenders of health services over the past two decades (e.g., physician extenders, nurse prac- titioners). I have been involved in that experience, working not only with new health professions roles, but with equal concern for the management support systems that form the receptive framework in which those people are to work. We have been engrossed in creating roles with linkages and translating capabilities between doctors and their communities. In our work in the Third World, the intermediate-level workers that we generically refer to as "medex" (most of whom are nurses) are now operating connectors, bridging the technical and cognitive distance between high-level profes- sionals and communities. The enabling mechanism has been created. The history I am talking about are the bonuses that this kind of COPC can bring to fee-for-service doctors if they have the guts and smarts to pursue it. I am talking about the increase in income and leisure time for physicians, the increase in coverage of some practices, and the maintenance of quality care that has been demonstrated in practices with medex-type workers. I am talking about the cost containment and, in some instances, demonstrated savings that resulted from the use of these primary care providers that can be passed on to consumers. But now that movement has plateaued and has actually begun to diminish for reasons that may not withstand the coming economic difficulties. The history I am talking about is the spreading of work of people like Ruth Lubic, producing 40 percent savings potential to patients and com- munities using birthing centers staffed by nurse-midwives. I refer to the use of nurse-anesthetists who give nearly half of the anesthesia in this country, while anesthesia residencies for physicians, already reduced in number, go unfilled each year. Someone else has had to fill the role, of necessity. This history that will be recorded in the next few months is work by McMaster University's Gregg Stoddard. I refer to a study that found that Canada could have saved S200 million in 1980 if the country had a na-

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Health Worker Roles 161 tionwide nurse-practitioner program. That number was a rock-bottom con- servative estimate, and Stoddard feels that between $500 to S600 million is a more realistic figure. Extrapolating that figure, which was for insured ambulatory services only under direct physician supervision, tO our own country, where we have proven that this type of worker can do much more with physicians and hospitals and communities, there could be an estimated annual cost savings of 55.5 billion. The possible working combinations involving communities, nurses, be- haviorists, doctors, community workers, and others to meet the needs of COPC are part of our history. Do we have tO wait two more decades to catch up with the Third World in appreciating the role of the community in PHC? Do we have tO be helpless spectators to nursing and medicine locked in their own agonies of change and adaptation. I think we would see nursing as the template for COPC in this country if we all could only look through the swirling dust together as we prepare for our roles in the strained period ahead. These problems and the history glaring at us are the backdrop against which the next difficult act is to be played. Fry W. Whitney The title of Dr. Hatch and Ms. Eng's paper is disarmingly broad for a nurse who views all patient contacts in primary care as health care contacts, thereby defining all who deliver care as "health workers." Their emphasis is upon the community-based person who may or may not be a formally trained health professional, but who is used to help integrate primary health care services into an existing community. My emphasis is on nursing and nurse . . . . practitioners In particular. An early (1929) model of COPC nursing is the Frontier Nursing Service, where midwives and public health nurses, responding tO community needs, brought to the hills of Kentucky a kind of health care that met not only the immediate need, but that has endured more than 50 years. Their epi- demiologic mode was called case-findings and has been the basis of primary nursing care since the beginning of nursing history. Early in my public health career, I found, perhaps less elegantly than the many examples in Dr. Hatch's presentation, the lesson of his three false assumptions. I began to fashion my practice after the needs of the community as they were expressed and found they were not very different from the professional intent just different in emphasis. I learned the language and, without throwing away my tools, learned how to build relationships that told me what the "real world" was. I was helped to understand by able teachers, my patients, their friends, and their neighbors that there was much to learn about people and how

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162 PART I: THEORETICAL ISSUES they behaved that no amount of formal education could bring to bear. More importantly, I learned the law of the consumer if they don't want it, they won't buy it. We call it noncompliance- they call it "no sale." What is often forgotten as we go about our planning for health services is that the initial choice to use or not use services rests in the hands of the patient. As Keith Bolden has said, "the patient is the cornerstone." It is only after he has given himself up to the system that he is in danger of losing control of choice. In primary care, the patient never truly does so. In teaching nurses to be nurse practitioners, what one does is move the center of focus from acute to primary care. Nurses are largely educated in acute care settings. Nurses with baccalaureate, masters, and doctoral degrees have some practice in community health, but they comprise only 15 percent of the nurses. Less than 30 percent of nurse practitioners are baccalaureate prepared. It is an interesting task to reorient the nurse to situations where it is the patient who determines whether or not he will follow the plan prescribed. Nurses are edgy and angry when patients return and have not "complied" with "what they were told." Dr. Hatch has suggested that community health workers can perform at least three tasks: (1) translator, (2) linker, and (3) enabler. Each of these tasks is concerned with negating the three false assumptions that he feels will impede the development of COPC in any community. The tasks are role-related. In the last 15 years, nurse practitioners have been very suc- cessful in primary care. They, too, have been translators, linkers, and en- ablers. Dr. Hatch suggests that the communication role is vital to both understanding and change strategies that will have lasting effects on the population. Nurses learn to view the patient/provider interaction as a team event early in their practice. The nurse is a credible provider in primary care, because the background brought to delivery of service is an action-oriented, patient-centered thought process, concerned with seeing an outcome rather than merely entering an input. Many recent studies show the effect of adult nurse practitioners (ANP) in reducing numbers of hospital visits, pediatric nurse practitioners in increasing patient compliance with well-child regimens, and nurse mid- wives in reducing the number of low-birth-weight babies born out of hos- pitals. There is evidence of improved hypertensive outcome in ANP clinics and reduction in the number of low-birth-weight babies and child abuse following delivery in Teen Pregnancy Programs, run by nurse practitioners in high schools. Patients' attitudes of acceptance and positiveness toward their care with nurse practitioners probably stem from a long history of patient-centered nursing practice. Nurses use health workers in the com- munity more fully than other providers. The nurse knows and accepts these vital people as part of practice and can use the communication network that is provided with less confusion than many of the other health workers.

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Health Worker Roles 163 The linker is a person whose role is finding resources in the community that are not commonly known. Every profession or service provider has "contacts," people who can help unwind the famous "web of causality." The linker gives the provider true diagnostic tools from an inside perspective, teaching them the role that will effectively accomplish the patient/provider mutuality of purpose. Nurses have acted as the informant "linkers" for years. They are the second opinion in the neighborhood. As nurse prac- titioners they continue to use this system in productive ways. The enabling role is the role that produces the effect. It is the role that must come third. It requires successful working through of the other two. The enabling role is one that requires skills in negotiation. The political and power elements of the community are involved. Often, in this situation, the provider becomes the liaison, the translator, and the linker. They are effective only if they have maintained appropriate relationships with the power structures outside and inside the community and can bring credence to the situaton based on understanding and power within that structure. Nurses have long been enablers. They have been called "handmaidens," "left and right hands," "advocates," "go betweens," and "gap fillers," and, of late, some less admirable things such as meddlers and protagonists or competitors. In primary care, nurses are often the vehicle through which things get done. They have been inordinately successful. They are often the ones closest to the community and tO the establishment. They live where primary care patients are. Our figures relating to graduates show that of 250 graduates, 75 percent have returned to the underserved areas from which they came. National figures show that 69 percent of nurse practitioners are practicing in primary care, most of them in inner-city or rural areas. I am constantly asked, what do nurse practitioners do? After 2 days of this conference, I can say with assurance, they practice in a COPC model as part of a health team, responding in individual ways to meet the needs of the "community," however defined, in which they find themselves. An- other question is, are they effective? The terms effective and efficient are often intermixed. Efficiency is often used to describe the outcome as ef- fective. How many patients can they see? Effectiveness is more complex than efficiency. Nurse practitioners do not see as many patients per minute as physicians. If they do, they are probably not doing an effective job as a nurse practitioner. We do know that 50-51 percent more patients are seen in practices with nurse practitioners and physician's assistants; that they provide 64-73 percent more direct patient care time in practices than was provided before; and that practices with nurse practitioners have a 42-51 percent increase in income. But primarily, nurse practitioners must be concerned with whether services produce desired results lasting effects and changes in social and personal structures. There have been many ef-

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164 PART I: THEORETICAL ISSUES ficient services. Even in Togo, walls were painted, education classes held, mothers taught, but still mothers did not come; services were not effective. It is this aspect of COPC that makes it so important to understand and accept the roles of health workers other than physicians. From my perspective, there are some threats to COPC that will have an impact upon its effectiveness in the United States. The Graduate Medical Education National Advisory Committee (GMENAC) report, while telling us that there will be an oversupply of total numbers of physicians, warns that there will not be an oversupply of primary care physicians. It also tells us that relocation of physicians to primary care settings will not be over- whelming. The National Institutes of Health predict that, although 60-70 percent should be in primary care, only 39 percent will be. The GMENAC report does suggest holding firm on the introduction of increased numbers of nurse practitioners and physician assistants during the next 10 years, until it can be seen whether physicians will take up primary care roles. It is my guess that they will not. However, regardless of what medicine does, it is inaccurate and short-sighted to suggest that limiting the practice of one category of health professionals will necessarily affect the problems of mal- distribution within another. Studies have proven that nurse practitioners, while they share many primary care roles, do provide distinct and needed services in primary care. We know that much of the move to block adoption of appropriate legislation for the practice of nurse practitioners in several states has been through physician groups. In New York State, this is true. They appear to want control of the practice of nurses who might compete with them. They want to hold in line all health professionals so that they may direct all activities in health. Several speakers have stressed a different tack for the future in COPC. Donald Madison called for a team of health providers to share and develop methods of health delivery. Luana Reyes said that it was not a medical community that must be developed, but a heal~h-conscious community. Nora Piore spoke to a deployment of re- sources that was a reflection of the epidemiologic needs of the community. Dr. Guerrero outlined a WHO definition of primary care that could not possibly be fulfilled by a single health professional. To Steve Joseph's four pillars, I would add a fifthother health workers. As David Kindig suggests, studies of communities will help define services, and, I would add, not unless the kind and number of providers available for particular purposes . . . are written Into t. he equation. Another threat is the present payment mechanisms that exist for reim- bursing health providers for services. Fred Diaz suggests there are two kinds of patients those who can pay and those who cannot. The largest block of patients are those who do not but rely on third-party payers. The fee- for-service structure, coupled with third-party reimbursement that centers

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Health Worker Roles 165 most of its payback on high-technology services, rather than preventive, primary care, has sent us reeling toward uncontrollable costs in the past 10 years. Although there has been legislation to ensure that health care is a "right," none of the plans to support it have included increasing costs for primary, preventive services, nor to include other, less costly, effective health workers in the payment scheme. Weston's study (Weston, 1980) regarding nurse practitioners shows that nurse practitioners in rural, un- derserved areas are largely deterred by lack-of-payment mechanisms for their services. Except in some federally designated centers, services pro- vided by health professionals other than physicians cannot be reimbursed. Many of the clinics that might have fallen under the Rural Health Act were unable to fit the guidelines. Many closed. No health care replaced the primary health care provided by nurses and physician assistants in these clinics. Primary nursing services, many of which are the needed services in the communities and which interact with the social, environmental, and community life-style needs, cannot now be purchased through third-party reimbursement mechanisms. Although I share Karen Davis' optimism for the increasing role of health care providers in helping define and direct the distribution of scarce resources in the coming months, I see little movement to include primary care nurses in the decision-making process. To exclude them is to maintain an economic status quo that will not only topple the economic health of the nation, but also fail to develop the needed team concept of COPC and, in the long run, fail the citizens who need our combined advocacy to create a climate of health and productivity. Last, continued dependence upon the vertical hierarchy of present-day organization of services will not bring us closer to usable models in primary care. We need to understand and implement matrix structures in health, with multiple providers and varied project and functional roles. There are many roads to health. It is important that the organizational structure of services does not form the roadblock to utilization and ultimately to access. COPC services must have flexible structures that reflect the best mix of people, payment mechanism, and methodology to do the task. If we are to look at health care as part and parcel of the social and environmental structure of the community, we cannot continue to weave a fiber that has only one dominant profession, a single answer, or an eco- nomic and organizational structure that is neither efficient nor effective. Use of community health workers, nurses, physicians, social workers, home health aides, respite programs, day care centers, elder programs, and the like will be a better approach to team solving of complex issues in the community. Dr. Geiger has asked, is COPC a romantic dream or a practical necessity? From my view, we do not have the luxury of the romantic dream. The

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166 PART I: THEORETICAL ISSUES necessity is upon us, and the solution is practical. To Dr. Abramson's two essential elements we must add multidisciplinary health team. Without this there is no ability to provide an integrative curative, rehabilitive, preventive, and promotive plan or comprehensive approach, as outlined in the essential elements of COPC. We need a team, whose captain is the patient, whose playing field is the community in which he lives, whose league is made up of a broader scope of players, and whose coaching staff has the good sense to call upon each other to provide their special skills for the purpose of winning the many faceted game of health delivery. Because we have already begun, I am sure we can do it together. BIBLIOGRAPHY Daniels, L. (1981) Nurse Practitioners in Idaho: Characteristics, Attitudinal and Role Perceptions and Scope of Practice. Study published for the Idaho State Board of Nursing. Johnston, T. (1980) Ambulatory Health Care in the 80s: Looking Ahead to a Decade of Dilemmas. Am. I. Nars. 80: 76-79. Lurie, E. (1981) Nurse Practitioners: Issues in Professional Socialization..~. Health Soc. Behav. 22(March):31-48. Miike, L. (1979) The Future of New Health Practitioners. Fam. Comman. Health 2(3):65-78. Mitchell, F.H., and Mitchell, C.C. (1980) Entering the 1980s: The Health Care System and Primary Care. Fam. Common. Health 3:105-08. Schemer, F NJ., Yoder, S.G., Weisfeld, N., and Ruby, G. (1979) Physicians and New Health Practitioners: Issues for the 1980s. Inquiry. Sox, H.C. (1979) Quality of Patient Care by NPs and PAs: A 10-Year Perspective. Ann. Intern. Med. 91:458-59. Sullivan, J.A., and Warner, I.S. (1979) Economic Perspectives for Nurse Practi- tioners. Public Health Rep. 94~2): 142-47. Systems Sciences (1978) Survey and Evaluation of the Physician Extender Reim- bursement Experiment. DHEW Contract SSA 660-76-0167. U.S. Congress, Congressional Budget Office (1979) Physician Extenders: Their C~r- rent arid Future Role in Medical Care Delivery. Washington D.C.: U.S. Government Printing Office. U.S. Department of Health and Human Services, Health Resource Administration, Graduate Medical Education National Advisory Committee, Alvin Tarlov, Chair- man (1981) Vol. 1: Summary; and Vol. 6: Non-Physician Health Care Provider Panel. DHHS Publ. #81-651 and 81-656. Washington, D.C.: U.S. Government Printing Office. Weston, T.L. (1980) Distribution of Nurse Practitioners and Physician Assistants. Implications of Legal Constraints and Reimbursement. Public Health Rep. 95:253- 58. Wirth, P., Storm, E., and Kahn, L. (1977) An Analysis of the Fifty Graduates at the Washington University Pediatric Nurse Practitioner Program. Part I: Scope of Practice and Professional Responsibility. Nurse Practitioner 2(6):18-23.