At the Center for Health Worker Innovation, we provide a platform for our partners and others in global health to share their perspectives on the health workforce. To that end, the following piece is authored by Denise Octavia Smith, CHW, MBA, PN, Executive Director, National Association of Community Health Workers.
When formerly enslaved Africans and their descendants left America in the 1820s, sailing east across the Atlantic headed to the newly forming colony of Liberia, a nexus was formed among persons of African descent in both countries in pursuit of freedom and racial justice.
Over the next 40-years, at least 12,000 U.S. Blacks migrated to that strip of land in West Africa—without sufficient supplies or money and facing new deadly diseases. Many perished there, while millions of their counterparts in the U.S. continued to suffer and die under chattel slavery and then Jim Crow.
From that time until today, health disparities, inequity and injustice—all made worse during the COVID-19 pandemic—level disproportionate impact on people of African descent in both countries. I find shocking similarities when comparing the health status of Black women in the U.S., the wealthiest nation on earth which spends more per capita than any country on healthcare, and women in Liberia, considered one of the poorest countries in the world.
As a Black woman living in the U.S., a mother of four, a Community Health Worker (CHW) and the Executive Director of the National Association of Community Health Workers (NACHW), I’ve concluded that the only solution for the twin terrors of gender inequity and structural racism found in the COVID 19 public health crises lies in sustaining policies and initiatives that respect, protect and partner with community health workers everywhere.
Women of African descent globally are disproportionately represented among the working poor and lag behind Whites in nearly every indicator of social economic status that impact their health and the health of their children across the lifespan.
In the U.S. and Liberia, for instance, Black women have high percentages of children who are food insecure (13.6% and 25% respectively) and both have poor birth outcomes with (1,072 Liberian maternal deaths for every 100,000 births) while Black women in the U.S. die at rates “320% higher than their white counterparts.”
The Community Health Worker workforce (which includes promotoras, community health representatives, aunties and dozens of other titles) is predominately female around the globe. We are natural helpers who leverage our shared life experience, trusting relationships, cultural respect for cultural traditions and practices and compassion with the persons where they live and serve. And yet our proven capacity to “extend the reach of healthcare,” and to improve health prevention, chronic disease and social service delivery has not resulted in sustainable funding, policies or a guarantee of fundamental worker protections.
When the COVID -19 pandemic began, global health leaders, health providers, legislators, policy makers and funders began calling for the rapid scale up and integration of CHWs to strengthen COVID response. In the United States CHWs were identified as critical infrastructure workers who should be paid to respond to the pandemic in March 2020.
But even as CHWs are heralded as critical to COVID testing, vaccination and response and recovery efforts, they remain the lowest paid among all health and public health professionals in the US and are frequently unpaid around the world, one of many lingering impacts of structural racism that includes inequitable access to COVID-19 vaccines, health care, and few worker protections. In Liberia and around the globe, most CHWs are often not paid at all.
Thus, during the pandemic, the vicious cycle of structural racism with its excess burden on women of color perpetuates poverty and loss of life while increasing threats to the health of their children already “living in the poorest countries, poorest neighborhoods and experiencing vulnerability”.
Since the COVID-19 pandemic began, few prominent initiatives have developed strategies to dismantle structural racism or prioritize gender equality. The Biden Administration’s National Strategy For the COVID Response and Pandemic Preparedness refers to “equity” over 55 times and promises to increase community partnerships, funding and training for CHWs. But it contains no urgent agenda for gender equality or a living wage for female workers or Black women who are disproportionately dying from COVID-19. A new National Strategy on Gender Equity, released in November 2021, promises to “address intersecting forms of discrimination and advance equity and equality” and “drive structural change”
The WHO Gender Equal Health and Care Workforce Initiative has identified 2021 as the Year of the Health and Care Worker. And while it seeks to increase visibility, dialogue, and commitment to action on gender equity in the health and care workforce, it doesn’t cite structural racism resulting from centuries of colonization and slavery as an explicit cause of the inequalities found among female health workers. Without that acknowledgement, the commemoration doesn’t hold much weight.
That’s why NACHW, a U.S. based nonprofit association whose mission is to unify CHWs across geography, ethnicity, sector and experience, partners with CHW-led organizations nationwide to amplify solutions and strategies in response to the daily stress, low pay, disrespect, and dangers CHWs experience on the frontlines during COVID -19. NACHW also co-founded the Community Based Workforce Alliance and Vaccine Equity Cooperative, led by CHWs, promotores and multi-sector leaders and their organizations. The goal is to prioritize racial equity principles for pandemic response, develop a playbook for authentic partnership with a community based workforce. The end goal is to fuel advocacy to ensure vaccine access, funding and policies that engage and sustain the expertise from our communities.
A similar effort is needed in low- and medium-income countries like Liberia, and all around the world. As COVID-19 continues to debilitate global economies, deepen inequity in vaccine and healthcare access and harm millions of families, CHWs have proven their commitment, expertise and effectiveness to drive trust, deepen relationships, protect families and heal communities. Now is the time to for public and private institutions to acknowledge that CHWs, who share life experiences and often live in the communities most ravaged by COVID-19, have been on the frontlines of this pandemic. At the same time, they continue to fight against persistent disparities caused by injustice for individuals and families.
Valuing CHWs through equitable pay—not glorified volunteerism—and ensuring worker protections for these women helps make pronouncements about health equity, community-centeredness and social justice meaningful, measurable and impactful.