Five years ago, I was working in Kono, a district in Sierra Leone, on projects to strengthen and reopen local health systems following the worst Ebola outbreak in history. The tasks included installing a basic electronic health record system in a local clinic, tracing contacts of people diagnosed with Ebola, and stimulating local economies. All of these activities depended on hiring, training, and mobilizing community health workers.
The results of that work impress me to this day. We should learn from them and consider employing them against Covid-19.
In Kono, as in the U.S. today, schools and universities were closed. But there was no infrastructure for online learning. This left many of the youngest, brightest, and strongest citizens bored at home, desperate to work, and enthusiastic about helping overcome Ebola in any way they could.
One of these was Vamba Lolleh. I met him while showing a group of newly hired community health workers how to extract data from mobile Android apps I had written using CommCare, a platform that collects data from mobile devices. The training consisted mostly of lessons for installing the software onto devices and extracting data and reports, but also a bit of coding so workers could make small modifications to the apps if needed.
The day after this training session, Vamba came to work several hours early. When I arrived, he was sitting under a tree messing with his phone. He approached me and demonstrated the app he had spent the night writing. I was impressed. He came to play a vital role in the post-Ebola response. When the epidemic ended in West Africa and I returned to the U.S., I was privileged to call him a friend and mentee.
I was pleasantly surprised two years later when Vamba reached out to me on LinkedIn and told me that he had continued the work we started and was leading technology efforts for more than 100 community health workers focused on surveillance and management of people with HIV and tuberculosis, two big problems in West Africa. (He is now an e-health officer with Partners in Health and is actively working on a Covid-19 screening tool for the Ministry of Health in Sierra Leone.)
Few people other than experienced aid and disaster relief workers might understand how rare Vamba’s message was. Most interventions fall apart minutes after the tents are pulled up and the staff depart. The fact that this effort was still funded, still running, and had grown so much was a testament to Vamba’s leadership and to the sound value of community health worker programs.
That’s an approach we should start considering right now as we fight Covid-19.
It’s great to see the expansion of telehealth, something that wasn’t available in fighting Ebola in West Africa. But we must also admit that technologies like that come with a significant last-mile problem: Patients seen by telehealth consults must still be physically tested if it’s likely they have Covid-19. They must still travel to treatment, supplies, and medicines. In fact, for positive cases, one benefit of telehealth is that it enables people with mild cases of Covid-19 to treat themselves at home, sparing precious inpatient resources for the most severe cases. But how best to facilitate the care of people outside of the already straining clinical infrastructure?
Community health workers are a proven solution for boots-on-the-ground needs such as contact tracing. Properly trained and protected, these workers make possible door-to-door assessments that can be so critical to containing infectious disease outbreaks. They can collect information on symptoms, progression of infection, patient-reported outcomes, contacts, and other data at a level of detail unattainable by any other means. Community health workers can also deliver test kits, transport samples to labs, distribute educational materials as well as medicine, food, and other essentials to those who need them.
Another important opportunity for community health workers is working in research and clinical trials. While critical care will be delivered hospitals, the current strategy is to treat as many people with Covid-19 at home. This is especially true for mild cases in highly vulnerable populations such as the elderly.
Recent FDA guidance acknowledges the unique challenges of conducting trials during the Covid-19 pandemic, such as limiting clinic visits and the associated risk to the infirm, such as bringing immunocompromised cancer patients to clinical site visits where they may be exposed to coronavirus, but also to ensure proper trial conduct such as minimizing protocol deviations or lapses in chain of custody of data or experimental products. Trained community health workers are a proven solution for this aspect of clinical trials as they can deliver supplies, complete case report forms, perform basic physical exams, and more.
If projections that the U.S. will be as devastated by Covid-19 as Italy has been, we must listen to the lessons taught by community health workers in West Africa and elsewhere and find ways to treat as many people at home as possible.
Building community health worker programs takes specific experience, but there are plenty of people in the U.S. and elsewhere with that experience. There are also plenty of smart, healthy people who are sheltering in place or social distancing who would love to help. They are engineering and nursing students, highly computer literate and waiting to pitch in. They are current and former soldiers with experience in security, logistics, and supply chain. They are food and hospitality industry workers who have been laid off from their jobs who could be catering neighborhoods instead of weddings and banquets. Almost everyone who is healthy has something to offer.
Launching this workforce would also have an economic impact. As politicians and scientists debate the rationale and necessary extents of lockdowns and social distancing, community health worker programs put people to work and are likely to decrease the overall economic burden of disease during outbreaks.
The country needs to recruit community health workers, train them in infection prevention and control measures, and give them the protective gear to keep them safe — though some could even help make that gear.
Many Americans have never seen a pandemic or the hardships that accompany it. As best we can tell, Covid-19 will get much worse before it gets better. Community health workers can help it get better faster.
Eric Perakslis, Ph.D., is a Rubenstein Fellow at Duke University.