Journal of Health Care for the Poor and Underserved

Community health workers (CHWs) have gone by many names in many countries: community health representatives, accompagnateurs, barefoot doctors, promotores de salud. Although they differ in important ways, they share the common goal of bringing basic health care to the communities they come from. In the United States, CHWs have never caught on as a national institution in part because they have not been considered economically expedient. Atul Gawande, in his January 2011 article “The Hot Spotters,” suggests that this might be changing.^1[p.48] American physicians, statisticians, and insurers are finding that a new permutation of the CHW model is in fact surprisingly good for the bottom line. The innovation behind what Gawande calls hot spotters is a focus on high-cost patients. By paying home visits to so-called superutilizers—patients who account for a disproportionate share of health care spending—and keeping them current on treatments and screenings and lifestyle modifications, they significantly reduce those patients’ long-term costs. By reducing costs on the most expensive patients, they reduce costs for the entire insured population. This naturally pleases insurers no less than clinicians. There’s nothing not to like about it. And yet one can’t help feeling a certain irony: Is it possible that the same CHW who has always been a favorite of social justice campaigners and left-wing governments will now become a favorite of America’s insurance industry? “We’ve been looking to Washington to find out how health-care reform will happen,” says Gawande. “But people like these [hot spotters] are its real leaders.”^1[p.50]

In light of the renewed interest in CHWs, I want to share a day that I spent last July shadowing a Salvadoran CHW—a promotor de salud—on his rounds of rural farmsteads in remote northeastern Morazán, El Salvador.

It was a sweaty one-hour climb up the volcano to our first visit. We turned off the road on a track slick with rocks, then onto a path yet smaller where bushes cut our arms. Adrian had to stop and wait several times while I wiped fog off my glasses or picked myself up from the mud. Adrian had been walking these trails for nearly three decades—as long as he’d been alive. He had been walking the trails as a promotor de salud since 2005, when the local clinic began using promotores in accordance with national policy. Since then he had worn through shoes too numerous to recall. In his backpack he carried patient charts, educational poster-books, a blood pressure cuff, a pediatric scale, and drinking water. [End Page 1497]

His shirt was much cleaner than mine but hardly less sweated through by the time we emerged from the forest into a small clearing planted with corn. At a makeshift fence of barbed wire Adrian called a greeting. Inside the fence was a sort of cage or coop improvised from scavenged wood. A woman stood inside. She stood very still, as though wishing for invisibility, but the boards of the structure were spaced so widely that she might as well have been standing in the open. Adrian called twice more, and finally the woman invited us forward. We squeezed through the wire and crossed the yard and ducked into the structure, and I was dismayed to find there a hammock and a fire pit. This was not an outbuilding of the farmstead, not a cage or a coop or a shed or a stable, but the farmstead itself. This was the home we had come to visit.

“It’s like the last time I was here,” Adrian told the woman. “We want to chat about health and see how your family is.” He looked at the fraying hammock and decided to keep his feet on the ground while leaning into it. Aside from the hammock, the only furniture was a bed frame; it had no mattress, nor any padding save for a sheet that hung between the wires. Awkwardly I took a seat there, and that left nowhere for the woman to...