Promotores de Salud in Montana: An Analysis of a Rural Health Care Intervention Rooted in Catholic Social Teaching and its Place in Medical Curricula

Abstract

The Latino population in the United States faces significant health disparities compared to their White counterparts. Community-based processes in Gallatin County, Montana, through academic-community partnerships have identified strategies to overcome these barriers. One such strategy includes the utilization of community health workers (CHWs) in the Latino population—in Spanish, “Promotores de Salud.” CHWs are often selected to target community health problems because they share the cultural, social, and demographic features of the population they serve. This paper explores the inherent ties between Catholic Social Teaching and the CHW health care model while focusing on a community-academic partnership in Montana that is implementing a CHW program. Catholic health care providers are called to apply CST principles to their health care systems and communities in order to achieve health equity for their patients. This paper proposes that community organizing and advocacy should be taught in medical school curricula across the country in order to promote physician involvement in solving public health disparities. Additionally, the authors suggest that practicing Catholic health care providers immediately incorporate community organizing through the use of CHWs to attain health equity for their patient panels.

Introduction

Across the United States, there is a mounting physician shortage affecting both primary and specialty care. The Association of American Medical Colleges reports that the nation can expect to see a shortage of approximately 37,000 to 125,000 physicians by 2034 (Association of American Medical Colleges 2021). While the physician workforce is facing shortages, the Latino population in the U.S. is experiencing significant growth (“Profile Hispanic/Latino” 2021). As this marginalized population continues to grow concurrently with declines in physician numbers, health care delivery must adapt to address their needs. To ensure quality care is delivered across vulnerable populations, physicians will require knowledgeable and skilled partners from within their communities.

Community health workers (CHWs) are partners that can be relied upon by doctors to address preventive health, health education, and community wellbeing in populations with barriers to accessing care. Catholic physicians must seek to serve marginalized populations in congruence with Catholic social thought. Although many studies have explored the efficacy of CHWs, a literature search using the terms “community health worker” and “Catholic” in the National Library of Medicine database reveals there are no papers exploring the intimate connection between CHWs and the rich social teachings of the Catholic faith (Behforouz et al. 2004; Brownstein et al. 2007; Duan et al. 2018; Franke et al. 2013; Little et al. 2014; Perry 2013; Perry et al. 2014). This paper will seek to illustrate the foundations of CHWs in Catholic social thought while exploring a unique academic-community partnership and its health care delivery strategy in rural Montana to address health disparities in the Latino population. This article will also discuss the importance of incorporating public health strategies like CHWs in medical school curricula to prepare the next generation of doctors to address gaps in health care.

Health Disparities in the Latino Population

According to the U.S. Department of Health and Human Services, Latinos make up nearly 18.5% of the national population (“Profile Hispanic/Latino'' 2021). Latinos compose 4% of Montana’s population (US Census Bureau 2019). While that figure is below the national proportion, Montana is considered a new growth community due to the rapidly expanding Latino population. In fact, over the last decade, Montana has seen its Latino population increase by nearly 50%—one of the fastest growths in the nation (Krogstad 2020). This growth has significant implications for health care providers in the state and across the rural Rockies.

Latinos often experience poorer health outcomes than their White counterparts. Foreign-born Latinos in particular are more likely to face discrimination in rural health care settings, resulting in a poorer quality of care and subsequent impacts on physical health (López-Cevallos & Harvey 2015). The COVID-19 pandemic has brought to light the inequities and harmful consequences of certain aspects of the US health care system that negatively impact minority populations. COVID-19 Latino case counts were twice that of the White population, and hospitalization and death rates were 2.8 times and 2.3 times higher than Whites, respectively (“Cases, Data, And Surveillance” 2021). Such COVID disparities were marked in states with less-established Latino communities like those in the Pacific Northwest. For example, a New York Times article from May of 2020 noted that Latinos made up 13% of Washington state’s population but accounted for 31% of the COVID-19 cases (Jordan and Oppel Jr. 2020). In Montana, Latinos made up 4% of the population but accounted for 8% of COVID cases ("Interim Analysis Of COVID-19 Cases In Montana" 2021).

Other disparities exist for Latinos in the US. The percentage of Latinos aged 20 and over with obesity is 45.8%, which is approximately 5% higher than their White counterparts ("Health Of Hispanic or Latino Population" 2021). They are also 50% more likely to die from complications of diabetes, and they experience higher rates of chronic kidney disease and cirrhosis (Hostetter and Klein 2018). The CDC further shows that 30% of Latinos aged 18–64 are without health insurance compared to just 10.2% of Whites ("Health Of Hispanic or Latino Population" 2021). Such inequalities in health outcomes and predictive measures are not due to ethnicity or cultural factors but likely due to social determinants of health. Such determinants include discrimination, economic situation, health care access, and educational opportunities (Gurrola & Ayón 2018).

According to a Pew Research survey during the height of the pandemic, approximately 49% of Latinos said they or someone in their household had taken a pay cut or lost a job compared with 33% of all US adults (Krogstad et al. 2020). The disproportionate rate of COVID-19 infection in the Latino community may be attributed to their work environment. Latinos are more likely to work in service industries that prevent proper social distancing and lack the opportunity to work from home (Webb Hooper, Nápoles and Pérez-Stable 2020). In addition, large numbers of Hispanic adults have been hesitant to seek vaccination against COVID-19 due to access-related barriers and immigration-related fears (Hoffman 2021). In a recent Kaiser Family Foundation study, many Latino adults stated they feared missing work due to the side effects of the vaccine or feared having to pay out-of-pocket for a vaccination (Hamel et al. 2021).

The disparities described above illustrate the need for health care providers and public health officials to tailor resources and address the concerns of an often marginalized community. As the Latino population grows in Montana and across the nation, it is vital for academic and medical leaders in the community to employ effective strategies to reduce health gaps. The strategy must also overcome barriers to seeking care, including cultural and social factors such as language and documentation status, respectively.

One such approach is through the use of community health workers who are focused on the Latino population. Promotores de salud [health promoters]—the Spanish-language equivalent—share cultural, social, and economic characteristics with the population they serve. Promotores are often distinguished members of their communities and are seen as a trusted source of information (Medina et al. 2007). They are utilized to address health disparities faced by their local population, an example of which will be highlighted in this article. It is critical for health care providers to address the root causes of health discrepancies between segments of society. This calling is most urgent for Catholic physicians and medical students who are guided by their faith and moral codes with a commitment to serving vulnerable populations, as will be discussed later in this paper.

Background on Catholic Social Teaching

Catholic physicians and medical students have a commitment to serving marginalized populations, such as the Latino community, according to Catholic social thought. Catholic Social Teaching (CST), which has existed in practice for centuries, is centered on the idea that every human being is created in the Imago Dei [the image of God], and therefore endowed with dignity and value (Benedict XVI 2006 no.2). The U.S. Catholic Bishops illustrate this core moral principle of the faith by stating, “As a gift from God, every human life is sacred from conception to natural death. The life and dignity of every person must be respected and protected in every state and in every condition” (United States Conference of Catholic Bishops 2001). Accordingly, every individual should be treated as equal regardless of social class, and governments must provide for the common good by ensuring stability and security to their populace.

In modern history, the six themes of CST include dignity of the human person, community focus, option for the poor and vulnerable, dignity of work and rights of workers, solidarity, and care for creation (United States Catholic Bishops 1986; Option for the Poor and Vulnerable 2021). However, the definition of CST was first formally defined in Pope Leo XIII’s 1891 encyclical, Rerum Novarum [Labor and Capital], which addressed labor concerns of the working class while refuting unfettered socialism or capitalism. Pope Leo XIII stated:

God himself seems to incline rather to those who suffer misfortune; for Jesus Christ calls the poor “blessed”; (Matthew 5:3) He lovingly invites those in labor and grief to come to Him for solace; (Matthew 11:28) and He displays the tenderest charity toward the lowly and the oppressed. (Rerum Novarum, 24)

Here, Pope Leo XIII highlighted the option for the poor and vulnerable found in CST. However, the idea of a preferential option for the poor was formalized by the World Synod of Catholic Bishops in 1971. An excerpt from the Synod highlights this claim:

Listening to the cry of those who suffer violence and are oppressed by unjust systems and structures, and hearing the appeal of a world that by its perversity contradicts the plan of its Creator, we have shared our awareness of the Church’s vocation to be present in the heart of the world by proclaiming the Good News to the poor, freedom to the oppressed, and joy to the afflicted. (Justicia del Mundo [Justice in the World] 1971, 5)

Additional papal encyclicals would go on to supplement both Pope Leo XIII and the World Synod of Bishops, including Saint Pope John Paul II’s Centesimus Annus [Hundreth Year] which states:

As far as the Church is concerned, the social message of the Gospel must not be considered a theory, but above all else a basis and a motivation for action. Inspired by this message, some of the first Christians distributed their goods to the poor, bearing witness to the fact that, despite different social origins, it was possible for people to live together in peace and harmony. (Centesimus Annus 1991, 57)

The United States Catholic Bishops further support Saint Pope John Paul II by stating:

We need to build on the good work already underway to ensure that every Catholic understands how the Gospel and church teaching call us to choose life, to serve the least among us, to hunger and thirst for justice, and to be peacemakers. (U.S. Catholic Bishops 2011)

Not only does CST proclaim the dignity of the poor, but also examples throughout the Bible and Catholic tradition speak to the rich history of caring for the marginalized as a vital component of the Catholic faith. The Catechism of the Catholic Church (CCC) states:

The Church’s love for the poor… is a part of her constant tradition. Those who are oppressed by poverty are the object of a preferential love on the part of the Church, which… has not ceased to work for their relief, defense, and liberation. (CCC, nos. 2444, 2448, quoting Centesimus annus [One Hundred Years], no. 57, and Libertatis conscientia [Instruction on Human Freedom and Liberation], no. 68)

This preferential option for the poor is mandated in the Gospels wherein Luke writes, “Blessed are the poor, theirs is the kingdom of God'' (Lk 6:20) and Mathew, “Truly I tell you, whatever you did not do for one of the least of these, you did not do for me.” (Mt 25:45).

The Catholic Worker Movement (CWM) is another Catholic religious movement that espouses the Catholic social thought on the rights and dignity of the marginalized. The CWM was co-founded by Peter Maurin and Dorothy Day in New York in 1933, sparking a movement across the nation to tackle social justice issues through the lens of the Catholic faith. At the start of the movement, Day penned an essay on the ‘Aims and Purposes’ of her philosophy:

We believe that all people are brothers and sisters in the Fatherhood of God. This teaching, the doctrine of the Mystical Body of Christ, involves today the issue of unions (where people call each other brothers and sisters); it involves the racial question; it involves cooperatives, credit unions, crafts; it involves Houses of Hospitality and Farming Communes. It is with all these means that we can live as though we believed indeed that we are all members one of another, knowing that when the health of one member suffers, the health of the whole body is lowered. (Day 1940, 7)

At its core, the movement upholds CST’s preferential option for the poor and marginalized. Day’s worker movement placed an emphasis on sending lay people as missionaries to the peripheries of society. By doing so, it applied CST so that everyone, including the lay people, could put into action the preferential option for the vulnerable.

The Worker movement’s emphasis on the interconnectedness of the common and solidarity is best supported by Saint Pope John Paul II when he wrote

When interdependence becomes recognized …, the correlative response as a moral and social attitude, as a ‘virtue,’ is solidarity. This then is not a feeling of vague compassion or shallow distress at the misfortunes of so many people, both near and far. On the contrary, it is a firm and persevering determination to commit oneself to the common good; that is to say to the good of all and of each individual, because we are all really responsible for all. (Sollicitudo Rei Socialis [The Social Concern] ¹⁹⁸⁷, no. 38)

Governments must also be involved in seeking out the common good. Pope Saint John XXIII stated, “It follows also that political authority… must always be exercised within the limits of the moral order and directed toward the common good” (Gaudium et Spes [Joy and Hope] ¹⁹⁶⁴).

The reverence for the dignity of the human person and the common good that forms the cornerstone of the Church’s moral teachings extends also to the ministry of health care (Condit 2016). Catholic health care has a duty to defend the sacredness of every human life from conception to death, while promoting the common good (United States Conference of Catholic Bishops 2009). In a short article from America Magazine in 1995, Dr. Paul Farmer wrote, “the… poor are more deserving of good medical care than the rest of us.” (Farmer 1995). He defends his statement by pointing out that the privation of the poor stems from economic and social exploitation, which are an affront to human dignity. Therefore, Catholic physicians are called to promote the common good by fighting the injustices which strip patients of their dignity and health both within health care systems and in wider society. Such Christ-centered health care has the ability to strengthen solidarity within a community while placing an emphasis on the common good (Cuellar De la Cruz & Robinson 2017).

Just as Catholics are commanded to make a preferential option for the poor, pathogens and diseases appear to be evolutionarily programmed to make that same option. The poor are at higher risks of dying prematurely from infection and chronic disease. For example, tuberculosis is one of the world’s top 10 leading causes of death from a single pathogen—higher than HIV/AIDS. Over 95% of cases and deaths occur in the developing nations and are correlated with HIV coinfection (World Health Organization 2020). Risk factors for infection with HIV include being single, having a low level of education, unemployment, low income, and substance use (Jiamsakul et al. 2018). Evidence has shown that low-income and middle-income countries bear a significant proportion of morbidity and mortality from non-communicable diseases (NCDs) (NCDs: World Health Organization 2010). Furthermore, within those lower-income nations, patients with lower socioeconomic characteristics have worse outcomes from NCDs (Di Cesare et al. 2013). More recently, Karaye and Horney found that social determinants of health such as minority status and language, household composition, transportation, and housing predicted COVID-19 infection during the pandemic (Karaye & Horney 2020).

The pathogenic preference for the poor caused by social circumstances must be addressed when Catholic charities and health care providers concern themselves with health care interventions in lower-income populations. To address such issues, place-based and culture-based knowledge has to be understood by all stakeholders. The authors propose this is an area where physicians can rely heavily on CHWs/promotores to identify, strategize, and overcome social barriers to population health.

The Role of the CHWs

The work of CHWs is Catholic social thought applied in a public health setting. They live and work in communities outside of health care and help promote healthy behaviors. CHWs receive training in community engagement, empathetic listening, and health topics for a set period, such as 3 months, with periodic continuing education, before engaging in their communities. Their roles vary considerably depending on the program in which they are trained and the needs of their communities. These roles can include administering vaccinations, offering vitamins, delivering health talks, connecting community members with health care resources, providing in-home neonatal care, teaching family planning services, providing basic first aid, and giving some simple diagnoses and treatments (such as parasites, malaria, and diarrhea) (Perry et al. 2014). One of the keys to the success of this health promotion model is the position of the CHW as a member of the culture and community they serve, fostering trusting relationships that are otherwise difficult to develop (Gampa et al. 2017).

The origins of CHWs can be traced to several previous initiatives. In 1973, the Christian Medical Commission and the World Health Organization (WHO) joined forces to promote the idea of community health advocates working as catalysts within their respective populations to improve health outcomes (Litsios 2004). Their goal was to improve the primary care model delivered by WHO across the globe. By 1975, the WHO and the United Nations Children’s Fund (UNICEF) released the Declaration of Alma-Ata that firmly defined the CHW as integral to the effective delivery of primary health care ("Declaration Of Alma-Ata" 1978).

CHWs were also used prior to the 1970s in Latin America. Populist governments of the 1950s in countries such as Perón in Argentina and Vargas in Brazil helped spur the development of liberation theology. Following years of meetings among prominent social and theological thinkers, Father Gustavo Gutierrez published Teología de la liberación [Liberation Theology], which formally detailed the newfound movement to empower the poor against their oppressors (Boff, Boff and Burns 1988). Promotores were crucial members of the liberation movement as they connected citizens to needed services and increased advocacy from within small, impoverished communities (Perez and Martinez 2008). In the 1960s and 70s, community health workers were also established in the United States’ Great Society programs. These CHWs were employed to help end poverty, promote equality, expand educational opportunities, and inspire environmental protection—evoking the core themes of CST. This program eventually produced CHWs focused on low-income neighborhoods and migrant worker camps through the Federal Migrant Health Act of 1962 (Migrant Health Act 1962).

Since that time, there has been ample evidence that CHWs are effective at promoting population health. CHWs help to reduce undernutrition, decrease mortality in children under 5 years of age, improve women’s health, slow the spread of HIV/AIDs, control malaria and tuberculosis, and reduce chronic disease, including hypertension, diabetes, and cancer, in developed countries (Perry et al. 2014). They work within a team of health care providers to bridge the gap between medical knowledge and community application and help to reach populations where there are barriers in access to care, whether that be due to lack of resources, lack of health professionals, or distrust of the medical system. One study found that “The effective functioning of large-scale CHW programs offers one of the most important opportunities for improving the health of impoverished populations in low-income countries” (Perry 2013, 10).

The implementation of promotores/CHWs are an effective way to overcome cultural and language barriers in the pursuit of health promotion. For example, Compañeros en Salud (CES), the Mexico-based affiliate of Partners in Health, recruited a network of acompañantes or local community health workers charged with caring for patients with chronic diseases. A study analyzing the effectiveness of the CES program found that diabetic management improved 12.8% following the introduction of its novel strategy (Duan et al. 2018). Through studying CES’ model in other locations such as Haiti, several studies have noted improved disease outcomes and medication adherence among AIDS patients when accompanied by a CHW (Behforouz et al. 2004; Franke et al. 2013). In the United States, systematic reviews of randomized controlled trials of a CHW-led program among Latino patients with diabetes found there were significant decreases in A1c in addition to improved medication adherence (Little et al. 2014; Brownstein et al. 2007).

The purpose of CHWs is fundamentally based in Catholic theology and culture, incorporating the six themes of social teaching, emphasizing community, and promoting health and disease prevention, thereby building the health of the community as a whole. More specifically, CHWs apply the CST principle of option for the poor and vulnerable, as they are an effective means to serve the health needs of the marginalized. Likewise, the method of CHWs is rooted in Catholic models of evangelism and discipleship. In the Gospel of Matthew, Jesus speaks to his disciples

All authority in heaven and on earth has been given to me. Go therefore and make disciples of all nations, baptizing them in the name of the Father and of the Son and of the Holy Spirit, and teaching them to obey everything that I have commanded you. And remember, I am with you always, to the end of the age. (Mt 28:18–20)

While Jesus, in his power and authority, could have individually reached all the nations, he chose to send out individuals into the communities. Similarly, Jesus also says to his disciples “The harvest is plentiful, but the laborers are few; therefore, ask the Lord of the harvest to send out laborers into his harvest” (Mt 9:37–38). Christianity’s emphasis on sending out disciples parallels the CHW model of sending forth health workers to their local communities.

Furthermore, the New Evangelization, emphasized particularly by Pope Benedict XVI, supports this model by calling on all Catholics, especially the laity, to proclaim the Gospel (New Evangelization 2021). In the opening sentence of his 2010 Apostolic Letter “Ubicumeque et Semper” [Everywhere and Always], Pope Benedict XVI states, “It is the duty of the Church to proclaim always and everywhere the Gospel of Jesus Christ” (Benedict XVI 2011). The CCC supports Pope Benedict XVI by stating:

This duty (to share the divine message of salvation) is the more pressing when it is only through them that men can hear the Gospel and know Christ. Their activity in ecclesial communities is so necessary that, for the most part, the apostolate of the pastors cannot be fully effective without it. (CCC, nos. 900, referencing Lumen gentium [Light of the Nations], no. 33)

Just as laity are needed to proclaim the Gospel, so too are CHWs necessary to promote the health of a population. Otherwise, the “apostolate” of physicians cannot be fully effective or adequate.

Montana-Focused Strategy

Montana State University (MSU) in partnership with a local community clinic for underserved patients founded the Gallatin County Promotores Program in 2013 (Nitzinger et al. 2019). The program was founded due to the rapidly growing numbers of Latino community members in Gallatin County and the lack of Spanish-language resources available to them. In describing its founding, the community clinic executive stated, “All of a sudden [in 2006] we were hearing Spanish being spoken in our waiting rooms almost daily” (Stifler Wolfe 2020). Consequently, the founders of the Promotores Program held focus groups, which resulted in the recruitment of six volunteers as CHWs, and trained them in health promotion skills via workshops conducted by health professionals. In Autumn of 2017, the Promotores Program transitioned to the Gallatin City-County Health Department to ensure the sustainability of the operation. The sustainability of the program is critical for the state of Montana, particularly Gallatin County, where there are booming service and construction industries which rely on an immigrant Latino labor pool. Construction in Gallatin County is estimated to employ approximately 6572 people, making it the third largest industry in the county (“Gallatin County, MT | Data USA” 2021).

In 2019, another Montana State University-based team focused on Latino health and wellbeing was formed, which included the first author of this article. This group termed their initiative, “Proyecto SALUD,” an acronym for Scientists and Latinos United Against Disparities, and is composed of interdisciplinary faculty and students from the university’s College of Engineering, College of Nursing, and other departments (Moyce et al. 2020). Their approach uses community-based participatory research (CBPR) and community engagement to empower the Latino community through health screenings, education, and training. The partnership employs community-targeted, community-based, and community-driven research to guide its development. This process ensures that the population of interest guides the direction of the research and involves community members as active and equal study facilitators.

The approach of Proyecto SALUD is aligned with CST. Although much in western academia has been separated from other forms of knowledge, such as traditional ecological knowledge, the connection between CBPR and CST is apparent. One of the tenets of CST is that all people have the right to participate in society and contribute towards the common good (Pope John XXIII 1963 no. 56). CST holds that it is morally wrong for certain groups to be excluded from participation in community. In western culture which often celebrates individualism over the common good, CBPR invites stakeholders to come together to achieve common goals. The most basic step then involves meetings between researchers, members of the community, and other interested parties to reflect on the needs of the community-at-large. This provides an opportunity for shared decision making, sincere dialogue, and deep listening to take place.

The Proyecto SALUD team followed the Association for Community Health Improvement’s Community Health Assessment Toolkit, which provides a nine-step pathway for conducting population health assessments and effective interventions (“Community Health Assessment Toolkit | ACHI” 2017). The steps include the follwing:

• 1. Reflect and Strategize

• 2. Identify and Engage Stakeholders

• 3. Define the Community

• 4. Collect and Analyze Data

• 5. Prioritize Community Health Issues

• 6. Document and Communicate Results

• 7. Plan Implementation Strategies

• 8. Implement Strategies

• 9. Evaluate Progress

The researchers at MSU invited members of Gallatin County’s Latino community to initial meetings to achieve the first three steps in 2018. Eventually a Community Advisory Board was formed with stakeholders from the Latino community to forge a trusting and working relationship, allowing for future health care concerns to be addressed by the combined resources and knowledge of both groups. In February of 2020, the SALUD team conducted a health screening event where over 100 participants convened. The fair was held at the local Catholic parish where many participants already felt comfortable. SALUD found that 20% of participants had no insurance and 40% had no regular primary care provider; additionally, over 74% of participants were overweight or obese (Moyce et al. 2021).

The team then organized focus group sessions with Latino community members to discuss and prioritize community health issues. Mental health was identified as a primary concern, which was likely exacerbated by the COVID-19 pandemic, causing social isolation and work-related fears (Moyce et al., under review). Having identified mental health as a major concern, along with nutrition, chronic disease, and physical activity, the SALUD team began planning intervention strategies. The work is currently in progress, but plans include developing the Promotores de Salud program, operated and funded by the county health department, to expand their reach into the peripheries of the community. As mentioned earlier, this model has shown success across the globe. For example, the CHW-effort in Chiapas, Mexico pioneered by Partners in Health, was associated with a twofold increase in the odds of disease control and management (Newman et al. 2018). In Gallatin County, CHWs can be trained using Latino-specific modules that are culturally appropriate, empowering them to tackle pressing health issues in the county. Mental health and issues relating to the pandemic could be addressed by CHWs in the near future using this model. The previous success of CHW initiatives, especially in Latinos, is promising for rural, immigrant populations in the United States.

The Promotores effort underway in Gallatin County is CST in action. The project aimed at improving the health and wellbeing of the Latino population in the county was generated at the local Catholic parish where several research team members attended. From this fellowship in faith, they began developing a program that could address some of the health care issues of their brothers and sisters in Christ. The initiatives brought forward by the Promotores program, including community health fairs, community-driven health boards, and community health workers, are all fundamentally based in CST.

As mentioned earlier in the paper, the six themes of CST are dignity of the human person, community focus, option for the poor and vulnerable, dignity of work and rights of workers, solidarity, and care for creation. Race and cultural barriers exist for Gallatin’s Latino community members, especially for those who are undocumented, which result in the undermining of their God-given dignity as members of the Mystical Body of Christ. As stated earlier, stigmatization and dehumanization of minority and immigrant populations can result in delaying care or limiting access to various public health resources. Addressing these barriers at the local level through CHWs, as the Gallatin County Promotores program is attempting to do, brings to life the CST theme of upholding the dignity of the human person. Other strategies, like free health fairs and stakeholder focus groups, are community-focused and revolve around solidarity with one another, another CST theme. It falls upon physicians and health systems, especially those who identify as Catholic, to provide a preferential option (such as free health fairs or immigrant-focused CHW programs) for the Latino population, a third theme of CST.

The work underway in Gallatin County is one such strategy employing a community-focused health intervention seeking to protect human dignity while providing health care and health knowledge to a vulnerable population. This outreach to the community can be adopted and adapted by other Catholic health providers to enact CST in their communities for the betterment of the marginalized and forgotten.

Translation to Medical School Education and Medical Practice

Leo Eisenstein, a fourth-year medical student at the time, published a parable to illustrate the need for physician advocacy and involvement in public health initiatives (Eisenstein 2018, 509–511). To paraphrase it: A bystander sees a person drowning and chooses to get in the river and save the victim. Shortly after, another drowning victim is quickly approaching the bystander. Again, the bystander saves the victim. This continues, and at some point, the bystander chooses to walk upstream to see why so many are drowning. The bystander discovers a bridge has collapsed, so people are forced to wade across the river. Subsequently, the bystander builds a new bridge and the flux of drowning victims ceases.

This parable is an analogy for everyday clinical practice. Health care professionals can become acutely focused on the patient or the set of symptoms presented in the examination room. However, principles of public health suggest that if health professionals take a step back and target the upstream causes of patient malady, true prevention occurs. For instance, by increasing access to fresh fruits and vegetables in food deserts, physicians can indirectly combat diabetes, heart disease, and adverse cardiovascular events (Kelli et al. 2019).

Community organizing and advocacy training in medical school increase community engagement in post-residency practices (Coutinho and Dakis 2017). Too often, physicians graduate without having real exposure to the public health sector or with little understanding of the strategies used to target population level health determinants. Community organizing, for example, involves a collaboration between community members and stakeholders to identify areas of inequity and ways to reform the disparities. It empowers individuals to work together to create meaningful change. In Gallatin County, the process led to the development of a CHW program between the university, area medical professionals, and the health department.

Medical students are instructed on social determinants of health and their consequences but are often not given pragmatic guidance to address these health-related issues. At the University of Washington School of Medicine (UWSOM), an elective course on community organizing is offered to first year medical students based on the ideals of health equity.Medical training that incorporates advocacy and community organizing ultimately improves patient health and has been shown to prevent physician burnout and increase overall life satisfaction (Eisenstein 2018; Horwitch 2018). This is a crucial point. When physicians feel powerless in the face of the constant river of health inequities and the diseases they produce, they can utilize CHWs as part of an integrated health team to address the upstream causative factors.

From the local community and medical school campus, the authors recognized the interconnectedness of CST and community organizing through exposure in their curriculum. Therefore, along with non-Catholic classmates, the authors invited Proyecto SALUD to present community-based research to the class. From SALUD’s presentation, the medical school cohort learned of the Promotores program and health fairs conducted by the research team. Following this introduction, Proyecto SALUD then requested help from the medical student cohort to help with health screenings, including measuring BMI, blood pressure, A1c, and mental health at their next health fair. In June 2021, SALUD hosted their second health fair. The authors of this paper, along with three classmates, conducted the health screens.

These student-physicians ventured into the community to spread awareness and empower a marginalized community regarding their health. While not CHWs themselves, the students were able to glimpse the importance of developing trusting relationships and meeting the community members where they are, just as CHWs do. They were able to eat tamales with the community, talk about life and family, and educate patients about their health. The results of the data collected from this health fair will be reported in a subsequent publication.

Conclusion

This article successfully illustrates the intimate connections between CST and CHWs by exploring the development and implementation of each. The authors argue that CHWs are the fruition of CST in health care. Both CST and CHW-led public health outreach rely on the use of laypersons sent to the peripheries to lift up the lowly and fight for the common good. Furthermore, the foundations of CHW’s can be found in the Latin American Liberation movement and the Catholic Worker Movement of the 20th century. Fundamentally, however, both CHW strategies and CST place an emphasis on solidarity with one another.

The paper also demonstrates how Catholic medical students can learn to affect health outside of the examination room and employ CST in their public outreach. The authors connected a community partner, whose model of engagement is reflected in CST, to their medical school cohort. While the project remains in early stages, and the Promotores de Salud model has yet to be expanded and fortified, medical students were able to further foster a relationship between the medical community and an immigrant population. The strategy in Gallatin County, MT, which incorporates CHWs, advocacy, and community organizing into medical student training, is a promising model for addressing health disparities across marginalized communities, be it rural or urban.

Recommendations

Just as the great Latin American Saints and martyrs did in the 20th century, Catholic health care workers have a responsibility to be immersed in their communities, to advocate for marginalized patients, to incorporate cultural-minded practices in their clinics, and where appropriate, work to advance CHW programs in their communities. As Dr. Paul Farmer explains in his book Pathologies of Power,

Solidarity is a precious thing: people enduring great hardship often remark that they are grateful for the prayers and good wishes of human beings. But when sentiment is accompanied by the goods and services that might diminish unjust hardship, surely it is enriched. To those in great need, solidarity without the pragmatic component can seem like so much abstract piety. (Farmer 2003, 146)

The authors advocate for public health initiatives, which are rooted in CST, to be incorporated into medical training and physician practices. Community organizing should be an integral part of every medical student’s training so that these skills are learned alongside traditional medical education. Medical curricula could discuss the CHW model as a tool in a physician’s or clinic’s toolbox to address community health problems to prepare students for addressing systemic injustices facing their patient panels.

The health disparities that exist in the United States, and in rural Montana, cannot be solved in the patient examination room alone. Physicians should rely on an integrated team of health care providers to go into the community and meet their patients in their own environment, especially in marginalized and underserved populations. They should specifically consider incorporating CHWs into their practice and developing health outreach strategies.

These recommendations are not solely for the benefit of the patient, which is evident, but for the physician’s job and life satisfaction as well. By embracing the tenets of community organizing and advocacy, physicians and medical students can aid in the elimination of systemic disparities that traditionally make health care providers feel powerless in the face of such insurmountable challenges. CHWs can be a Catholic model of health care delivery and serve as a crucial component in a physician’s toolbox to address these challenges, especially in the face of growing shortages of physicians across the nation. Health care systems and medical schools should therefore be encouraged to adopt this health care delivery model across the nation.

Biographical Notes

Nathaniel Sisson is a second year medical student at the University of Washington School of Medicine enrolled in the Targeted Rural and Underserved Track. He also works as a Graduate Research Assistant in the Moyce Immigrant Health Lab at Montana State University. His interests include family medicine, global and public health, and working with marginalized populations.

Jenna Starke is a second year medical student at the University of Washington School of Medicine. Her interests include family medicine, palliative care, community organizing, and working with underserved communities.

ORCID iDs

Nathaniel Sisson https://orcid.org/0000-0002-3351-1419

Jenna Starke https://orcid.org/0000-0002-1084-8537