She had been showing up at Parkland Health & Hospital System’s emergency room for basic medical care. The patient, a Hispanic woman in her 70s with congestive heart failure and diabetes, was struggling to find safe and consistent housing.
The community health workers Vidya Ayyr manages at Parkland helped the patient get a walker, better housing, clinic appointments and medication during the pandemic.
“We take a very culturally sensitive approach,” said Ayyr, the hospital’s director of social impact. “We have to take the time to build the relationships to understand the needs of the community.”
When infectious disease hits, under-appreciated community health workers on the front lines can have a big impact. They help track infection, monitor the infected, test for the virus, collect data, transport food and supplies, and conduct outreach and education. Their importance is greatest in underprivileged and under-served communities like southern Dallas, which are disproportionately affected during a public health crisis like a pandemic.
Cuts to public health have thinned their ranks over the years. But exploding U.S. unemployment as well as billions of dollars in forthcoming stimulus money has given rise to an idea: the creation of a new public health workforce to help fight the COVID-19 pandemic and also rescue the economy. More than 750,000 Texans filed claims for unemployment pay in a three-week surge that followed stay-at-home orders in the state’s major cities.
Some say a public health workforce could be modeled after the Works Progress Administration, which helped lift the U.S. out of the Great Depression.
“They share one underlying quality and that’s empathy,” Ayyr said of her front-line health workers. “We definitely need more of them.”
President Franklin D. Roosevelt created the WPA in 1935 to put more than 8 million Americans back to work during the apex of the financial calamity. During an eight-year period, numerous public infrastructure projects were completed under the ambitious government program.
“There is going to be a need for a community mobilization to help those in need who are just going to struggle from this,” said Dr. John Carlo, former medical director for the Dallas County health department. “We’re going to need boots on the ground.”
The idea could get traction — in Dallas and beyond. The director of the Harvard Global Health Institute recently called for such a mobilization in this new era of deadly communicable disease to help with prevention, detection and response efforts.
Vidya Ayyr manages community health workers at Parkland Health & Hospital System in Dallas.(Parkland Memorial Hospital)
“It is going to be like a WPA. It’s going to be about putting people to work,” said Carlo, CEO of Prism Health North Texas. “It’s an important thing we should start thinking about now.”
Ayyr said her four Parkland community health workers live in the communities they serve and often face some of the same social barriers. She called community health work a “very grass-roots preventive movement” that stresses eating right and overall health and wellness.
“These are the same people you live next door to or go to the same church with,” she said.
Carlo said COVID-19 will likely be with us for some time as successive waves of infection strike, so workers will be in demand for the foreseeable future.
Community health workers require a minimal amount of training compared to health care professionals like nurses, Carlo said. They provide advocacy as well as education, and serve as a liaison between their community and local public health and social services agencies.
Social distancing can hurt poor communities, Carlo said, where households tend to have more people. More will get sick and have fewer resources to manage their illnesses, and those without transportation will have difficulty buying food, he said.
New data shows that black communities in the U.S. are suffering disproportionately from infection rates and related hardships. The Dallas Morning News recently reported that poor, black and Hispanic communities in south and central areas of Dallas have the largest share of people with diabetes, heart disease and other chronic health problems associated with severe COVID-19 cases. As a result, they are more likely to end up in a hospital intensive care unit, The News reported.
UNT-Dallas student Kevan Wise (right) and alum Darnell Davis unloaded boxes of food from a North Texas Food Bank truck on March 31, 2020, at UNT-Dallas in South Dallas. The boxes were loaded into the cars of those in need of food because of the coronavirus outbreak. (Jeffrey McWhorter / Special Contributor)
Despite having a head start as other countries like China struggled with COVID-19, the U.S. found itself unprepared.
“To just put in money when there is a disaster, as we’re finding out, doesn’t work so well,” said Catherine Troisi, an infectious disease epidemiologist at the University of Texas Health Science Center’s School of Public Health in Houston. “You need to have the infrastructure up and running and ready to go all the time.”
Texas counties, she said, did not have enough people trained to handle contact tracing, for example — the process of interviewing the infected to find out whom they had contact with in preceding days and weeks. The U.S., as a result, is now well beyond the containment phase.
“Health departments are just overwhelmed trying to do that work because they’re short-staffed,” said Troisi, who used to work for a public health department.
Community health workers “can relate to their community and really know the community’s needs,” she said. Those needs are as great after the containment phase, when a disease is widespread, Troisi said.
Troisi said she supports a WPA-like program for public health and communicable disease issues. There is plenty of other work needed, she said, in the areas of heart disease, diabetes prevention, nutrition and exercise.
“It could be expanded to other health issues,” she said.
A Dallas County official said the county does not keep statistics on its community health workers. Troisi said that for the past 12 years or so, funding for public health programs has evaporated.
“If you can’t see a problem, then public health is doing its job right,” she said. “They’re preventing things. And that’s hard for politicians and the public to understand.”
Troisi said she hopes the COVID-19 pandemic serves as a wakeup call. The military doesn’t just build up during wartime, she said.
“There’s always a level of protection there,” she said. “It should be the same with public health.”
The problem is public health’s impact isn’t immediately apparent, Troisi said, adding that it’s difficult for politicians to put money into something that may or may not happen like disease outbreaks. Conversely, potholes need fixing right now, she said.
Sometimes money is made available to address a growing health problem like tuberculosis, she said. And the number of cases go down. And because funding is tied to the number of cases, money is cut and then the number of cases rises again. Troisi said she’s heard that phenomenon referred to as the “U-shaped curve of indifference.”
Aerial view of medical professionals working at a Dallas County drive-through COVID-19 testing site at Ellis Davis Field House in southern Dallas on March 24, 2020.(Smiley N. Pool / Staff Photographer)
Erin Carlson, an associate professor at UT-Arlington’s College of Nursing and Health Innovation, said Texas has an impending shortage of public health professionals, as well as inadequate funding.
“Our public health workers are disproportionately older than the general workforce, and we have disproportionately fewer millennials represented in public health than the overall U.S. workforce,” she said.
While there may be new opportunities for people to join the public health workforce, the bulk of the latest stimulus package — about $127 billion — is for health care, not specifically for public health, Carlson said. She added that about $4.3 billion will go to the Centers for Disease Control and Prevention for states to hand out to local health departments.
Carlson said she hopes some of it will be used to “create new preparedness positions at the state and local levels.”
Denise Hernandez, president of the DFW CHW Association, said the region has about 500 certified community health workers who are employed by hospitals, private health care firms and health insurance companies, among others. They’re also losing their jobs during the current economic disaster, and many are caretakers for their own families, she said.
“Our health professionals are short-handed and need additional help,” Hernandez said. Community health workers “are the perfect people to make that connection and be that bridge.”
Hernandez said community health workers are especially needed during a pandemic — to drop off bags of food on porches; help people set up video conferencing software for telemedicine appointments and school lessons; to check on patients with chronic conditions; and to gather toiletries to distribute.
The need remains
Raj Panjabi, an assistant professor of medicine at Harvard Medical School, wrote in an article for the World Economic Forum that community health workers were a key element of the world Ebola response, going door to door with nurses to educate people about the disease. They helped detect signs of the virus and got patients to go to hospitals, he said in the article.
“When Ebola threatened to bring us to our knees, community health workers did not surrender to fear,” Panjabi wrote. “This same community-based strategy is critical once again in our global response to COVID-19.”
John Carlo was medical director of Dallas County Health and Human Services during the 2009 H1N1 swine flu epidemic and is now CEO of Prism Health North Texas.(Courtesy of John Carlo)
Carlo said the need for such work isn’t going away when the curve flattens. New coronavirus strains could emerge through mutation, he said, or other people will become infected eventually when social distancing restrictions are eased.
“Without a vaccine or a medication that limits the severity, we’re going to be with this a long time,” he said.
Meanwhile, Ayyr said her Parkland health workers are calling at-risk patients at home to help them cope with feelings of isolation, fear and anxiety during the COVID-19 crisis. She called it a “beautiful reward” to see vulnerable people get the care and housing they need. She described it as the epitome of the Golden Rule.
“It’s caring for others the way you want someone to care for you,” she said.