Promotores: A New Breed of Health Care Provider

At age 28, Marcos Francisco is still studying to complete his high school equivalency degree. He hardly fits the usual image of a health care provider. Yet he is just that as, speaking his native Mayan with a sprinkling of technical words in Spanish, he cajoles, warns, and tries to persuade members of his Kanjobal Indian community to come to the Everglades Health Center in nearby Florida City.Most of Marcos' young listeners -- farm laborers who work in the tomato and strawberry fields in the Everglades -- are skeptical of his "new" wisdom. They worry less about their health problems -- which can range from tuberculosis to alcoholism to AIDS -- than about work and having a roof over their heads. Still, he listens diligently and answers their questions, drawing on an intensive six-week training course at a local clinic.Marcos is one of seven "health promoters" working with the non-profit Community Health of South Dade, which oversees clinics in half a dozen towns in the county. Around the country, perhaps a few hundred more men and women, operating within their own communities, are helping people break through the growing cultural and economic barriers to health care. They work under various names -- as "sister friends" in Chicago, "cultural mediators" in Seattle, "promotores" here" -- in keeping with the cultural dynamics of their communities.These programs have been growing in the U.S. since the 1960s, inspired by the success of "promotores" in Latin America and "barefoot doctors" in China. Because they are so local, no one knows exactly how many currently operate in the U.S. -- a problem that may be resolved when a national network of health care providers meets in New York next month. Sponsors -- including the Annie E. Casey, Walter Johnson and Kaiser Family Foundations -- believe as funding cuts and the move to managed care make medical care less accessible, these promoters may be the only friendly face of health care for marginalized communities in the U.S.Marcos and his colleagues have a particularly tough task. They are trying to stretch the health care safety net to cover the one group in the work force at greatest risk for infectious or occupational illness -- migrant farm workers.In downtown Homestead, Alfredo Valle tries to reach his "client" -- a migrant and drug addict evicted from his apartment for beating his wife -- by sharing stories in the slang of their native El Salvador. Mario Medina has found that Mexican folk tales help break the ice, so his countrymen take it less personally when he starts talking about family planning."We Mexicans are very sensitive to certain words, actions, and body language," says Hilda Ochoa, who manages the promotores project (called "Opening Doors") for the South Dade center. Though promotores are not professionals in the usual sense, "they come from the community. They know how the people think, what time to find them at home, when to use the familiar 'tu' -- a professional can hardly do this."Forty years ago, Ochoa says, her farmworker father walked for days with a huge abscess until he reached Mexico rather than ask for help in California.Farm workers suffer disproportionately from illnesses linked to poor nutrition and parasites and rank second in incidence of job-connected accidents. Yet fewer than one in five has access to a health clinic, according to the National Center for Farm Worker Health in Austin, Texas.Health workers say the situation can only get worse as the immigration and welfare reform laws of 1996 cut more holes in farm workers' safety net. At least one suicide -- a 75 year old man in Stockton, Ca., a farmworker for over 40 years who thought his SSI benefit would end -- has been directly attributed to confusion over the status of benefits. Meanwhile, deportations by the busload are becoming a fact of life in farm labor camps, and those without papers know that jail penalties are increasingly likely."It's scary to think what will happen to immigrants without public assistance," says Brodes Hartley, Jr., director of the South Dade center, "but we are not abandoning them." He believes more and more centers like his will rely on promotores to help them deliver health care.Since clinics are reimbursed, to some extent, on the basis of patient load, community health workers can actually keep a program viable. In the eight years she has been leading a promoter effort in Salinas, California, Terry Gomez has seen the number using the clinic double, allowing it to be self-sustaining.In Florida City, Marcos Francisco wants to continue with his studies after finishing his GED. But government spending cuts mean he will have to rely on some philanthropic source to realize his desire to go to medical school, let alone serve as a bridge between the thousands of uninsured Indian migrants and the English and Spanish speaking worlds of Florida.PNS HAS PHOTOGRAPHS FOR THIS ARTICLE. CALL 415-243-4364 FOR MORE INFORMATION.

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