Mark Brender is national director of Partners In Health Canada
To fight the spread of COVID-19, the federal government has been recruiting volunteers to help public-health agencies trace the contacts of people who have tested positive for the virus. This turn to volunteers might suggest that reaching out to potentially infected persons is of secondary importance to the hospital-based heroics of professional pandemic-fighting, but nothing could be further from the truth.
In fact, it highlights an important reality: Canada needs to invest in community health workers (CHWs). They are essential in our health care system – in times of pandemics and not – and they should be paid.
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In the absence of a vaccine, the treatment of the novel coronavirus is reactive, not pro-active. But contact tracing actually prevents disease. The virus has exposed the need for a public-health system that more strongly integrates community-level responsiveness with the needs of vulnerable populations as part of its daily practice, as well as in times of crisis. This is where CHWs could play an important role.
The global health non-governmental organization Partners In Health (PIH) has been making this argument for years, backed by successes implementing a paid CHW model around the world. From Haiti to Lesotho to Peru, CHWs are a detect-and-support system for vulnerable populations. Living in the communities they serve, CHWs regularly visit the homes of families and patients. They become the eyes and ears for clinics and hospitals, building trust and long-term relationships that allow them to accompany patients to higher-level care. They have been central to the treatment of HIV, tuberculosis and other chronic diseases and to contact tracing for cholera in Haiti, for example, and Ebola in Sierra Leone and Liberia.
In the United States, which has stumbled badly in its handling of COVID-19, one policy bright spot getting attention is Massachusetts’s decision to partner with PIH to hire and train hundreds of staff to do contact tracing, based on a CHW model, in order to support the state response. The contact tracers make phone calls to let people know they may have been exposed to the virus, and to share information on testing, quarantine and how they can protect themselves and loved ones.
But the workers also understand that many people, for a variety of economic and health factors, simply cannot follow these instructions on their own. Contact tracing must be coupled with social support to ensure access to food, sanitation and suitable quarantine housing for those who need it. A separate group of callers serve as resource co-ordinators, connecting contacts with community services that make it possible for them to follow public-health directives. The resource co-ordinators must understand local context, have empathy and be good listeners.
We would do well to follow the example of Rwanda, which has 45,000 community health workers for a country of 13 million people and a separate, centralized contact-tracing system that has been highly effective in containing virus spread. Every contact of a person who tests positive for COVID-19 is traced, tested and entered into quarantine or isolation with food, shelter and social supports.
Despite CHWs’ proven successes, policy makers routinely challenge the viability and effectiveness of paying them – in both wealthy and impoverished settings. In situations of poverty, volunteer community health workers often are portrayed as the inexpensive panacea for all ills – conveniently ignoring the health workers’ dire need for income. In rich countries, community-care structures are often overlooked in favour of specialized hospital care. This undervaluation of community-level health services is one reason why we’re now witnessing Canada’s federal government cobble together a volunteer public-health cadre, many weeks into a pandemic.
Disease outbreaks may be inevitable, but health crises and their common victims – the poor, the senior population, the homeless, Indigenous populations, prisoners, people of colour – result from political choices. In a country as rich as Canada, we have no excuse not to invest in the human capital and community supports that would allow core public-health activities to be fully effective year-round.
It is neither radical nor revolutionary to have paid community health workers present within a health system, ready to respond in times of urgency. Their efforts, and the social support they facilitate, should be a core part of any public-sector provision of compassionate and effective health care.
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