CHWs and Social Determinants of Health: How Far Upstream Are We Looking?

It is time to critically assess how community health workers (CHWs) “address the social determinants of health” as members of primary care teams. The language of upstream medicine has rapidly gained traction. Published descriptions of CHW effectiveness in linking patients/clients to transportation, housing, and related social services are coupled with calls to integrate CHWs into mainstream health care delivery and financing to achieve Triple Aim objectives of health care reform.

The presenters—a CHW leader and a former state health official—will describe risks associated with imprecise thinking about CHW impacts and the growing emphasis on support for licensed clinicians as the primary CHW role.  One is the risk of marginalizing effective work many CHWs do in communities and outside the health care delivery system.  Another is the risk of diminishing advocacy as a CHW core competency, especially since CHWs must often confront institutional barriers to quality care within their own organizations.  Third, we risk placing excessive expectations on CHWs and obfuscating the distinction between linking people to services and transforming institutionalized racism, gender discrimination, oppressive power structures, and inequitable resource allocations that underlie health disparities.

The session will combine practice-based examples with a critical literature assessment to document ways in which CHWs help ameliorate ill effects of social determinants of health.  It will emphasize that achieving the Triple Aim requires social justice, fidelity to the WHO Marmot principles, and political and community organizing.  Promoting primary prevention is a responsibility for all health and public health professionals, not just CHWs.