Eva Salber is Professor of Family and Community Medicine at the Duke University School of Medicine in Durham, North Carolina. Last year I had the privilege of visiting Dr. Salber at her home in nearby Chapel Hill and discussing her important work promoting the role of lay health care volunteers in community medicine. The following report is drawn from my conversation with this truly remarkable woman.
"The great majority of illnesses," Dr. Salber observed as we sat in the comfortable downstairs family room of her home, "are never seen by a physician. The real primary care is provided by one's family, close neighbors, and friends. Furthermore, in every community there are certain people to whom others turn for advice, counsel, and support. I call such individuals health facilitators. And one of the most important things any doctor or other health professional can do is to find these people and offer them recognition, information, and support."
Eva Salber, you see, is a champion of the lay health facilitator. She has taught medical professionals from many countries how to help and benefit from these unsung heroes and heroines who, in fact, have always provided a great deal (if not the majority) of the world's health care. Dr. Salber is quick to say, however, that she isn't the force behind the "barefoot doctors." Rather, she has simply pointed out their existence, and suggested ways they might be given the recognition and support they deserve.
Witch Doctors and "Ill Wishers"
Eva's interest in lay health care was kindled by her experiences as a staff physician at one of South Africa's first Institutes of Family and Community Health (the forerunners of the neighborhood health centers in the U.S.). "We learned very quickly," she recalled, "that the local medicine men could deal with certain kinds of troubles better than we could. They were much more effective in handling family and personal problems because they were part of the local culture. And, of course, they knew just what to do with afflictions that involved the client's belief system. If a woman felt that she was being poisoned by an ill-wisher, for instance, we might be able to name her symptoms, be we wouldn't be able to cure her. We learned to refer such cases to the witch doctors. They in turn sent us any patients with the sort of ailments — they called them 'town diseases' — for which our tools were more effective, including VD and other infections that could be cleared up with antibiotics. My great triumph came when the local witch doctor sent one of his wives to me for treatment."
After her introduction to the health facilitator concept, Eva began to notice the same phenomenon wherever she went — including Boston, where she served as director for a health program in a low-income, inner-city housing project. "In spite of the hardships such as poverty, broken families, crime, unemployment, and poor education that housing project residents had to contend with, the neighborhood could boast of an active, effective network of health facilitators who spent a good deal of their time helping others," said Eva. So she put together an advisory committee for her program and appointed the community's health facilitators as members, placing these people in positions of responsibility and power for the first time in many cases. The move was a success. "I've seen it time and time again," observed Dr. Salber. "People want to give, and to be given, the opportunity to help. When provided with that chance, they'll blossom before your eyes."
The Health Advisor Project
"By the time I came to Duke," said Eva, "I was convinced that there are natural health facilitators in every community. So I decided to see whether I could develop a program to help others identify these individuals, to supply them with any information they needed, and to link them with useful groups and agencies in the community."
Her project took place in two villages in rural Durham County, and in an adjoining urban fringe area. A questionnaire had already been designed for a health survey of the region, so Eva simply tacked on an additional question: "Other than doctors, who do you know around here to whom people go for advice on health matters?" As soon as the results came in, Eva began knocking on the doors of the people mentioned, asking if they'd be interested in participating in a program that would give them the opportunity to meet other amateur helpers and to learn methods of aiding their neighbors more effectively. Nearly all the people Eva contacted accepted her invitation.
A Very Special Group
"We ended up involving 39 health facilitators in the program," Eva continued. "They ranged in age from 16 to 70. Two-thirds were women, 28% were housewives, 13% were professional health workers, and 10% were ministers. They tended to be exceptionally mature, secure, caring people, but in terms of age, race, and education, they represented a typical cross section of the community's residents.
"During our first meeting, which was held in the basement of a local office building, we talked about the program's overall goals and asked the facilitators to suggest topics of interest. Then in subsequent meetings we held workshops on one or more of those subjects, with the discussions led by the most knowledgeable and interesting people we could find in the fields involved. The areas we covered included self-diagnosis, over-the-counter drugs, diabetes, hypertension, sickle-cell anemia, childhood illnesses, folk remedies, first aid, growth and development, nutrition, sexuality, substance abuse, and health promotion. In addition, we had a session on community resources led by someone from a local information and referral organization."
Furthermore, Eva's group held discussions based upon brief tape-recorded dramas staging hypothetical situations, such as one in which a woman tells her sick neighbor that her illness "sounds a lot like what I had" and gives her a leftover prescription drug. Four program coordinators were also appointed to maintain support and communication among the participants between the meetings. To do so, each coordinator would visit a number of the facilitators in their homes once a week to discuss and deliver information packets on topics requested by the lay workers (the most popular subjects included angina, sickle-cell anemia, VD, hypertension, heart disease, arthritis, asthma, and cancer).
The Facilitator's Role
In addition to providing education and support for the community's lay helpers through her program, Eva studied the nature of the workers' cases. She found that they were handling everything from colds and other minor illnesses to problems as serious as cancer, alcoholism, and attempted suicide.
"The range of difficulties that people brought to the facilitators was much wider than the range brought to doctors," Eva explains. "Only about 3% of physician visits are for psychological ailments, yet there's a much greater need for such help. One has only to read Ann Landers' column to realize that people yearn for assistance with almost every conceivable type of individual, social, and family anxiety. And if a person with multiple problems does go to a physician, it will almost certainly be only the physiological distress that receives attention. We learn that, if we want to see a doctor, we must focus our concern on a physical symptom. A woman might tell her physician that she has a bladder infection, but she might tell a health facilitator that she had a fight with her husband, lost her job, and has a bladder infection."
In fact the lay people in Eva's study (and remember, these are individuals who aren't paid, for their services, and who in most cases are holding down full-time jobs and caring for families of their own) were asked for help about three times a week, on the average. In other words, the 39 facilitators in the project dealt with about 6,000 requests for aid and advice each year!
Facilitators in the Clinic
Eva is enthusiastic about the possibility of lay workers' assisting in clinical situations. "Let's say you're running a well-baby clinic," she suggested, "and you know a health facilitator who is also an excellent mother. Now suppose you have a neighborhood teenager just coming in with her first baby. You could ask the more experienced mother if she would be willing to advise the younger girl, and then ask the teenager if she'd like to be able to call on the older woman for help.
"The same thing could be done for people with asthma, diabetes, hypertension, or any other chronic disease. Just match a newly diagnosed patient with someone who has dealt with the problem successfully. I think such a system would be good for health professionals, too. They could learn a great deal from facilitators about the dimensions of illness that are never seen in a clinic — contributing factors such as marital and parenting problems, money worries, unemployment, poor housing, and so on."
Pillars of the Community
I asked Eva (who is now in her 60's) what she's learned from her experiences. She threw back her head and laughed. "If possible I've become more convinced than ever that, if you place these facilitators on an equal footing with professional health workers, if you show them respect, if you give them the opportunities to define and solve the problems in their communities and to help other people, they'll accomplish things you never dreamed were possible. And it takes so little to support these powerful, natural helpers.
"Furthermore, I've learned that health facilitators are everywhere. They can and should be used in every country, but particularly in those areas where professional services are few and there are many problems. These individuals can help inform professionals of the true needs and priorities of the region's people, they can extend services to those who need them most, they can support self-help activities among those who come to them for advice, and they can assist in guiding people to the appropriate professional care when necessary.
"I've learned that the natural helpers are real pillars of their communities. They are a resource that can no longer be ignored."