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Can ordinary citizens help fill gaps in U.S. health care?

October 17, 2016 at 6:25 PM EDT
In the midst of radical changes in health care policy, some U.S. providers are looking to an unlikely model: Sub-Saharan Africa, where ordinary citizens are trained as medical support for their communities. In the U.S., City Health Works is following suit, using community members to form long-term relationships with patients to fill gaps in care. Special correspondent Sarah Varney reports.

JUDY WOODRUFF: With the U.S. health care system undergoing its biggest changes in decades, health experts are looking to an unexpected place, sub-Saharan Africa, for inspiration.

Throughout the continent, ordinary citizens are routinely trained as community health workers. Sarah Varney reports on the lessons to learn. This story was produced in collaboration with our partner Kaiser Health News.

SARAH VARNEY: Destini Belton is on a mission to improve health outcomes in Harlem. She’s not a doctor or a nurse, but she knows this neighborhood and the people who live here.

Belton goes where clinics and hospitals can’t: Into patients’ homes, to understand the mundane but vital details of their lives.

DESTINI BELTON, Health Coach: Hi. How are you? Oh, your hair looks nice now. How are you feeling?


SARAH VARNEY: She visits people like Jessica Gonzalez, who was blinded by uncontrolled Type 1 diabetes at age 22.

DESTINI BELTON: Let me take your blood pressure.

SARAH VARNEY: Now 33, Gonzalez has high blood pressure, high cholesterol and renal disease, and Belton worries that she has trouble keeping her medications straight because she can’t see them.

DESTINI BELTON: You take most of them during what time of the day?

JESSICA GONZALEZ: During the day or after breakfast.

DESTINI BELTON: During the day.

SARAH VARNEY: Gonzalez is reluctant to admit her struggles to her doctor, but she trusts Belton to understand.

JESSICA GONZALEZ: With your doctor, you don’t really want to say what you eat, so I’m able to tell her like, really, if I’m not doing well, or, you know, if I sneaked and cheated. I tell her the right things, and she helps me.

MANMEET KAUR, City Health Works: East Harlem is historically known as El Barrio, it’s more of a Latino community…

SARAH VARNEY: Manmeet Kaur has trained a small team of these community health workers in New York City.

MANMEET KAUR: East Harlem in particular has the highest rate of diet-related diseases in New York.

SARAH VARNEY: The organization, called City Health Works, contracts with primary care providers, like Mount Sinai Health System, to better manage their most difficult patients.

TENISHA DEWINDT, Health Coach: Today, we’re going to be doing a workshop on healthy beverages.

SARAH VARNEY: Nearly all of their clients are poor and facing chronic illnesses that frequently spiral out of control. They work to stabilize their health and avoid costly visits to the emergency room and lengthy hospital stays.

Employing community health workers is a common strategy elsewhere in the world. In sub-Saharan Africa, community health workers have long formed the backbone of health systems, filling in gaps where doctors and nurses are in short supply.

It was Thandi Blie in Cape Town, South Africa, in fact, who helped to inspire Kaur to start City Health Works.


WOMAN: How are you?

THANDI BLIE: I’m fine. Thank you. And how are you, my dear?

WOMAN: I’m good.

THANDI BLIE: Long time no see.

SARAH VARNEY: They met when Kaur worked with a group called Mamelani Projects, a nonprofit that relies on regular women like Blie to help neighbors improve their health habits.

THANDI BLIE: I remember, last time, when we met, you had issues or problems about your high blood problem.

SARAH VARNEY: Often by sharing their own experience.

THANDI BLIE: Yes, because really high blood pressure is very dangerous. I know it from me.

SARAH VARNEY: She often shares how her once high blood pressure led to a stroke.

THANDI BLIE: I make the examples about what happens in me. Then, as soon as I share maybe a story, someone say, ‘And me, too.’

SARAH VARNEY: Long lines besiege clinics and hospitals in South Africa, where apartheid-era laws have left a legacy of widespread poverty and desperate health conditions.

Mamelani’s health coaches say that, just as in New York City, those realities are often best confronted outside the walls of medical clinics by bringing health education to areas that need it most. The women who’ve attended these classes are making lasting changes to their own health and in the wider community.

Mickey Linda used her own pension to start a soup kitchen after hearing that neighbors were taking powerful drugs to treat HIV on empty stomachs. With nutrition training from Mamelani, she now cooks up healthier meals for hundreds of neighbors and serves as a vital local health resource, keeping watch over her community.

MICKEY LINDA: Because doctors are not staying here. Doctors are staying in town. It’s us who see that we can talk about health to them, because we are staying together here. It’s us who see them, that this is this problem this problem.

SARAH VARNEY: Those close social ties undergird much of life in South Africa, says Mamelani’s founder, Carly Tanur.

She and her team are working closely with Manmeet Kaur back in Harlem to figure out how Mamelani’s model could be incorporated more broadly into the U.S. health care system.

But here in Harlem, the question is: How can this model fit into a sprawling hospital system like Mount Sinai, especially at a time when health care leaders are searching for ways to control the cost of caring for chronically ill patients?

With Medicare now penalizing providers for some preventable conditions, there are stronger financial incentives to steady the turbulent lives of people like Jeanette Rodriguez.

JEANETTE RODRIGUEZ: I was in emergency last two Fridays ago because I fell in the street.

SARAH VARNEY: Destini Belton is her go-to problem-solver, filling out paperwork for benefits, helping her find a caregiver program for her father. But she’s also a liaison for Rodriguez’s own medical needs.

DESTINI BELTON: So, the main things we’re going to ask when we get up there to the doctor is about your back.

SARAH VARNEY: At a nearby Mount Sinai clinic, that preparation has paid off.

Dr. Joseph Truglio tells Rodriguez she may have had a mild stroke.

DR. JOSEPH M. TRUGLIO: I know that’s got to be pretty hard to hear that that might have been something that happened.

SARAH VARNEY: Rodriguez had dismissed the tingling on her right side as arthritis, but Belton’s insistence and long relationship with her ensured Dr. Truglio would hear about it.

Plugging into their patients’ electronic health records, Kaur wants to make coaches an indispensable part of the health care system by professionalizing their role and proving their financial value.

MANMEET KAUR: We work with clinics to determine, how do we integrate our team into their operations? And that, we know, has resulted in patients feeling very confident in the services we provide, but also the doctors feeling really confident that they know more of what’s going on with their patients.

SARAH VARNEY: But Kaur goes home each night to one of her biggest skeptics. Her husband, Dr. Prabhjot Singh, is helping Mount Sinai figure out whether there’s enough evidence that efforts like City Health Works should be integrated more fully into Mount Sinai’s business.

DR. PRABHJOT SINGH, Mount Sinai Health System: I think the thought that comes up for a lot of my colleagues, and frankly my own, is: How do you do this for 40,000 people, 50,000 people at the scale of the Mount Sinai Health System?

SARAH VARNEY: Singh heads the Department of Health System Design and Global Health at Mount Sinai.

DR. PRABHJOT SINGH: We actually have to know whether or not the relationship between Destini and her client is effective. It may feel really good, but, from a health system perspective, and also just looking at health improvement, we have to really understand, is she getting healthier and are we doing it in a cost-effective way?

SARAH VARNEY: There are early signs the program is working. Patients with health coaches cost $600 a month less in medical care than a control group, a strong indication that coaches are preventing expensive medical emergencies. And for half the patients, coaches alerted doctors about urgent needs that they weren’t aware of.

While the program has worked well for people like Jessica Gonzalez and Jeanette Rodriguez, City Health Works remains a small venture, supported largely by foundations interested in testing the model. But the ultimate aim is to have public and private insurers around the country pay for thousands of coaches like Destini Belton … creating stronger ties between neighbors — like in sub-Saharan Africa — to help poor communities take control of their own health.

For the “PBS NewsHour” and Kaiser Health News, I’m Sarah Varney.

JUDY WOODRUFF: And you can learn about a community health initiative taking place in New York that aims to protect residents from unsafe summer temperatures.

That’s on our Web site,