Throughout history, community health workers (CHWs) have been integral to helping communities heal with regard to both physical well-being and healing from trauma as a result of oppression. To honor the first National Day of Racial Healing earlier this year, the National Association of Community Health Workers (NACHW) held an inaugural annual webinar to highlight the newly endorsed American Public Health Association (APHA) policy recognizing CHWs’ role as racial health advocates and the historical role of CHWs as healers.

Though the policy itself is within the APHA’s CHW section, Rumana Rabbani, MHA, CHW-VPP, and Abdul Bin Abdullah, CHW-VPP – the policy’s principal authors who presented the webinar along with NACHW – are from Community Healing through Activism and Strategic Mobilization (CHASM). Rabbani is CHASM’s director of strategic improvement and policy, and Abdullah serves as the director of programs and community mobilization.

CHASM is a community-led organization of strategic learning that aims to build capacity for CHWs and community-based organizations (CBOs) within historically oppressed communities, neutralize systemic inequities, and enhance harmony within the social ecology. The organization recognizes the deep “chasm” between health care and social determinants of health interventions resulting in the perpetuation and inequities within systems.

CHASM recognizes Historically Oppressed and Other Peoples Experiencing Inequities (HOPEIs) as people who were brought from Africa and enslaved in America, and Indigenous First Nations (including descendants of those groups who trace their genealogy back to Indigenous Mexicans, Aztecs, Mayans, Incas, etc.) whose land was colonized by Europeans. HOPEIs also include other populations experiencing inequities, such as women, Muslims, immigrants, LGBTQ+ people, people with disabilities, and others. However, due to the imbalance caused by the transgenerational and systemic nature of racism, historically oppressed people are prioritized in this specific work.

Addressing Racism as a Public Health Emergency

There is no clear universal strategy to address and dismantle systemic racism, especially with regard to public health. The policy authored in part by Rabbani and Abdullah is one potential approach that recognizes the value of CHWs in helping communities heal in a culturally appropriate and responsive way.

The policy, A Strategy to Address Systemic Racism and Violence as Public Health Priorities: Training and Supporting Community Health Workers to Advance Equity and Violence Prevention, addresses three main points:

  1. Systemic racism and violence have been widely acknowledged as public health emergencies; however, we currently lack comprehensive strategies that address the underlying causes of these public health threats.
  2. CHWs are well-suited and well-placed to address these underlying causes and reduce violence and racism.
  3. To make an optimum contribution to addressing racism and violence, CHWs need to be trained, supported, and provided with more opportunities through program development.

According to the webinar, APHA encourages external constituencies to take the following comprehensive actions to train, support, and measure the impact of CHWs to address systemic racism and prevent interpersonal violence among HOPEI communities most affected by inequities. APHA is calling on:

  1. Congress to pass, and the President to sign, legislation that allocates funding to federal agencies to then make sustainable funding and opportunities available to CBOs, researchers, evaluators, and more to develop effective strategies and collect consistent data.
  2. State legislatures to pass legislation providing funding to state health departments to take actions consistent with the above priorities.
  3. National and local CHW associations and CHW employers to endorse CHW training in interpersonal violence and systemic racism in this policy proposal.
  4. Foundations and other funders to take actions consistent with the above priorities and provide funding for organizations (especially those led by BIPOC and other HOPEIs) with experience training, hiring and retaining, and conducting research and evaluation with and about CHWs.
  5. Colleges and universities that train other public health professionals to include in their curricula information about the historical role and potential of CHWs to contribute to eliminating health inequities by addressing structural racism and violence.

“We need everyone at the table to address this problem that impacts us all collectively,” Abdullah said. “You can’t heal a community just by making them feel ‘more connected’ or that butterfly feeling, that’s not healing. To make me feel better and more connected, that’s one thing. But you have to also build efficacy, you have to help them learn how to actually stop the harm from continuously happening.”

Contextualizing the Structural Determinants of Health

Although social determinants of health (SDoH) — the social and environmental factors that impact one’s ability to be healthy – have become part of the public lexicon, Abdullah believes it’s important to understand the context of structural determinants of health to fully understand the need for racial healing. SDoH do not exist in a vacuum, they exist due to systems put intentionally into place to target and oppress certain communities, often communities of color. Specifically, as Abdullah puts it, colonizers have historically succeeded by limiting others’ ability to thrive.

The American Civil War presented an opportunity for a major turning point in the oppression of Black Americans as blood was shed to fight for the decision to end slavery. However, this opportunity was immediately lost with the addition of the 13th amendment to the Constitution:

Neither slavery nor involuntary servitude, except as a punishment for crime whereof the party shall have been duly convicted, shall exist within the United States, or any place subject to their jurisdiction.

By outlawing slavery and involuntary servitude except as punishment for crime, the U.S. created a loophole – “an exception to dehumanization,” as Abdullah refers to it — that set the stage for a new and now legal form of oppression.

One of the most prominent examples of this is the crack cocaine crisis of the 1980s. A major political decision stemming from the end of the Cold War was to prevent certain countries, including Nicaragua, from being successful. This led to the deliberate distribution of crack cocaine from the American government to communities of color, followed by a strict war on drugs in those same communities, as documented by the Drugs, Law Enforcement, and Foreign Policy report of 1988, also known as the Kerry Committee report.

“One of the things they were willing to do was allow for crack cocaine, specifically cocaine, by the thousands of tons, to be trafficked inside of the United States of America,” Abdullah said. “It was trafficked in communities that were predominantly Black and Latino. Within Black communities, that trafficking of crack produced this multi-million-dollar industry of violence and essentially self-inflicted war upon the community.”

Although gangs, crime, violence, etc. already existed, trafficking drugs on this scale created access to unprecedented wealth and power that drove conflict as people flocked to this culture, seeing it as a “way out” of poverty or oppression. As a result, gang presence and rates of crime and violence skyrocketed and took a toll not only on communities but on individual families as well.

The war on drugs also led to mass incarceration which grew exponentially and targeted mostly people of color. According to Abdullah, prison populations in the early 1980s were on average about 300,000 people. By the end of the 1990s, those populations rose to nearly 1 million. Prison populations have continued to grow steadily since, especially among Black Americans.

According to 2021 data from The Sentencing Project, there are currently 1,799,965 total incarcerated people. The ratio for Black incarcerated people compared to white is 4.8:1. For example, in a jurisdiction where the Black imprisonment rate is 1,000 per 100,000 Black residents and the white imprisonment rate is 200 per 100,000 white residents, the Black/white disparity would be 5:1.

An important consideration when discussing mass incarceration is that rehabilitation is also a relatively new concept, implemented within the last decade to help prepare inmates for their return to the real world. Before rehabilitation efforts were standard, people returned home from prison carrying baggage from the experiences that led to their incarceration as well as the new trauma they endured throughout their sentence.

“Crack cocaine produced violence at an escalated rate,” Abdullah said. “Gang violence then was coupled with the simultaneous attack by way of over-policing, and the war on drugs was really a war on the people. Those populations of people were then put into prisons. Those prisoners come home and do what? They interact with their families. They bring the trauma, they bring the violence, they bring more instability inside the community. A lot of brilliant people come home too, but the majority come home and bring their trauma and the learned culture of interpersonal violence back to the community.”

As a result, youth and elderly people in these communities became more exposed and vulnerable to toxic stress, which has been extensively linked to mental health concerns and chronic disease. Felons can also be legally denied housing, employment, and the right to vote, forcing them to remain in these communities while simultaneously limiting their ability to simply exist, let alone thrive.

Violence, abuse, and crime have always existed, but never thrived the way they do today, including and especially in predominantly Black communities. Abdullah raised the point that even throughout the Reconstruction era and Civil Rights Movement, when Black Americans were being publicly lynched and newly thriving Black communities were being attacked and destroyed, there was never a record of Black communities overwhelmingly harming each other. Oppression caused by mass incarceration, coupled with the culture of violence caused by the systemic oppression of affected communities, created the scale of violence and crime seen today.

“This is where we see the CHW being responsible for doing the most of this work whether it’s in Black, Latino, and Indigenous populations or other populations experiencing some form of inequity,” Abdullah said. “The full context of racial healing is something deep inside of our system that needs to be transformed. It’s not just inside the actual laws, it’s not just inside the systems, it’s inside the human being.”

The Path to Racial and Community Healing

The roots of CHWs run deep in both global and American history because humans have naturally stepped up to fill in gaps when their communities are being harmed. Though the name and exact definition has changed over time, the mission has always been the same. There is well-documented evidence that when care isn’t provided to oppressed humans, they will find ways to care for each other.

“Whoever is oppressing is not concerned about the health and well-being of the people they’re oppressing,” Abdullah said. “Those individuals that are being oppressed naturally step up and begin to support each other when it comes to being sick, being pregnant and birthing children, just trying to live a quality life under the oppression.”

Over time, CHWs became part of the formal American health care system, a process that required various regulations of the profession. However, in the 1980s, the sudden growth of immigrant and seasonal farmworking communities – and the members of those communities acting as caregivers – demonstrated that there were ways to provide care that didn’t fit into the strict, regulated mold.

Recognizing community caregivers as an asset and seeing their value as part of a solution helped shift the outlook of how community health could be delivered. In the 1990s, the CHW term was officially introduced as a neutral term to represent all unique types of community healers under one umbrella term, without discrediting the work of healers throughout history or outside traditional health care institutions. Fast forward to 2019: the National Association for Community Health Workers – the host for this webinar – is founded.

Shifting the Power Differential in Maternal Health

To address maternal mortality rates in Missouri, which disproportionately affect Black, Hispanic, and rural birthing people, Altruism Media, Inc. is delivering The Maternal and Infant Health (MaIH) Project. The MaIH Project deploys CHW and doula teams to communities throughout Missouri to connect pregnant and birthing people to a continuum of health care and social services, as well as provide hands-on support.

Together, the CHW and doula work with clients to assess their health needs, identify which social determinants of health may be impacting their ability to receive care (including insurance coverage, transportation, and more), and do the work to refer and connect them to local providers and resources, free of charge. Program participants are relieved from the burden of making appointments and finding rides and can instead focus on taking care of themselves and their child(ren).

Throughout their pregnancy and through at least one year postpartum, patients will continue to be followed up with by the CHW and doula team, who act as case managers to ensure they are receiving quality care, feel supported, and have their questions answered. The CHW and doula also advocate for patients, especially patients of color, as they navigate the health and social care systems.

As part of program development, The MaIH Project (and its CHW and doula teams) work to educate participants and their support systems about health literacy and how to advocate for equitable treatment. The goal of The MaIH Project is ultimately to shift the power differential from provider to patient and empower Black, Hispanic, and rural birthing people to take the lead in their perinatal care and feel supported by their care team.

To get connected to help, call or text 844.860.0111. Learn more about The MaIH Project. 

Watch the webinar, National Day of Racial Healing, to learn more about the historical role of CHWs and the APHA’s new policy.