2016

Bridging the Access

Gap between Home
and Hospital
Global to Local Community Health Workers in
South King County
Pearl Terry

PearlTerry
June5,2015
ANTH399:FinalProposal

Advisor Stevan
Harrell

BridgingtheAccessGapbetweenHomeandHospital:GlobaltoLocalCommunity
HealthWorkersinSouthKingCounty

Accesstoprimarycareandmentalhealthfacilitieshasbeencitedasoneofthe
mostvisiblebarriersinagrowinglypolarizedsocioeconomicgradienttohealthinthe
UnitedStates;inSouthKingCounty,lackofeconomicopportunity,culturalbarriers,and
anincreasinglycomplexandconfusingservicesystemareamongtheprimaryobstacles
identifiedbycommunitymembers(GlobalToLocalImprovingCommunityHealthin
SeaTacandTukwila2012).TheGlobaltoLocalprogramisahealthinitiativeestablished
in2010outofSeattle,Washington.Thisresearchprojectseekstoworkwithinthis
networktoanalyzethedevelopingpositionofcommunityhealthworkersintheKing
Countyhealthsystem,exploringhowthispotentialforcemaybeappliedinthe
reformationofAmericancare.SouthKingCountyprovidesauniquespaceforthis
analysis,asitincludessomeofthemostdiversecommunitiesinthecountry(Balk2012;
Felt2013).Thisresearchwillprovideauniquepointofanalysis,asnoglobalhealth
studyhaspreviouslyaddressedcommunityhealthworkersinsuchadiversedomestic
setting.Theoutcomeofthisanalysiswillprovidecriticalinsightontheviabilityof
expandingtheglobalhealthstrategyofcommunityhealthworkerstoastate,ifnot
nationallevel.Myprimarymodeofdatacollectionwillincludeindepthqualitative
analysisofcommunityheathworkersandassociatedculturalliaisonswithintheGlobalto
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Localprogram,aswellasaffiliatedHealthpointclinics,SwedishHospital,and
Harborviewmedicalcenters.Participantobservationandinterviewswillprovidemy
centralsourceofanalysisoverthecourseofthefollowingyear.

KeyWords
GlobaltoLocal,G2L,KingCounty,SeaTac,communityhealthworkers,immigrant
health,refugeehealth,healthcarereform,accesstohealthcare

Introduction
Lackofaccessandunderstandingbetweencommunitiesandmedicalinstitutions
haslargelycontributedtothetremendoushealthdisparitiesobservedintheUStoday
(Bowseretal.2015;Perry1997;Kripalanietal.2006;Marmot2009;Farmern.d.;
Farmeretal.2006).Thisdiscordance,betweenhealthsystemsandthepopulationsthey
arebuilttoservehasbeenacentralfocusofglobalhealthanalysisincountriesacrossthe
globe.Themostsuccessfulstrategiesdiscussedinglobalhealthprogramanalysishave
beencultivatedbyacommunitybasedtreatmentmodel,whichisdistinguishedbyits
methodsofemphasizingthediagnosisandaddressofcommunityidentifiedneedsover
individualizedtreatmentplans(PfeifferandChapman2010;Birnetal.2009;Farmer
2013).Ofthesecommunityhealthstrategies,mycentralpointoffocuswillbethe
utilizationofcommunityhealthworkers(CHWs),intheirapplicationastranslators
betweenindividualsandcommunities,andbetweencommunitiesandtheUShealthcare
system.CHWshavetraditionallybeenemployedinsituationsofculturalinterpretation

involvingimmigrantandrefugeepopulations.Butgiventheuniqueandinmanyaspects
foreignnatureoftheUSmedicalsystem,andtheskillsnecessarytoskillfullynavigate
suchasystem,IbelievethispositionofCHWasculture,orsystemsinterpretermay
havethepotentialtoimproveaccesstoprimaryandmentalhealthfacilitiesin
communitiesacrossalldemographics.IntheUnitedStates,CHWshaveonlyrecently
beenintegratedintothecareteam,andinlocalized,limitedcapacities.CHWprograms
havebeenusedasapointofexperimentalmeasureinstudiesofminoritygroups
identifiedbyspecifichealthrisksHispanicpopulationsandTypeIIdiabetestrials,
AfricanAmericancommunitiesandheartdiseasemedicationcompliance,etc(Sanders
andLehmann2007;HarrisE2009;Colleranetal.2012;Katapodi,Pierce,andFacione
2010).
ThecitiesofSeaTacandTukwila,suburbsofSeattle,aretwoofthemost
ethnicallyandculturallydiverseintheUnitedStates,ranking15thand11threspectively1
(Balk2012);theextremediversityfoundinSeaTac/Tukwilaissignificantlyhigherthan
anythingfoundinprojectsorstudieseverbeforeinitiatedinthefieldofGlobalHealth
(ImprovingOutcomesWithCommunityHealthWorkers2007).Cultural,aswellas
physicalandsocioeconomicbarriershavebeencitedasprincipalcontributingfactorsin
lackofaccessibilitytohealthcareforresidentsofSeaTacandTukwila,whosehealthcare
outcomesarecomparativelygrimwhenmeasuredagainstthoseofthesurroundingarea
1 Diversity was calculated using a formula based on racial
identification from the 2010 census; a perfect diversity score would
mean that all five racial/ethnic groups listed (White; Black; Hispanic;
Asian/Pacific Islander; Native America/Alaskan Native; and Multiracial/other) are represented equally in a given place. Each of the five
would have to be exactly 20 percent of the population to score 100;
Tukwila scored 91.5.
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(GlobalToLocalImprovingCommunityHealthinSeaTacandTukwila2012).Barriers
tohealthcareaccessdemandimmediateaddress,astheybareffectiveserviceto
marginalizedcommunitiesandfunnelpublicandprivateresourcesintoaninefficient
healthcaremodel.
TheGlobaltoLocalinitiativehasdevelopedastrategyforimprovinghealth
outcomesinSeaTacandTukwilawhichcentersaroundthisconceptofcommunity
developmentasanupstreamhealthintervention.TheGlobaltoLocalprogramisahealth
initiativeandglobalhealthcollaborationestablishedin2010outofSeattle.Theobjective
ofthiscollaborationistoimprovehealthoutcomesandreducehealthdisparitiesinSouth
KingCountybyimplementingsuccessfulglobalhealthmethodsinlocalcommunities;
theGlobaltoLocalinitiativecurrentlyemploys5CHWs,targetingincreased
communicationandpositiveinteractionwithSomali,Burmese,Latino,andEastAfrican
populationswithinthecommunity(G2L:GlobaltoLocal2013);thisnetworkof
communityhealthworkerswillbemyprimarypointofaccess.Throughindependent
studyofGlobaltoLocalshealthcaredevelopmentmodelandoutcomesonthediverse
domesticcommunitywhichitserves,acontributiontotheconversationofthehealthcare
reformmaybemade.
SouthKingCountyDemographics
TheareaoffocusforbothGlobaltoLocalandmyintendedstudyisSouthKingCounty.
ThoughonlyafewmilesfromSeattle,thecommunitiesofSeaTacandTukwila
demonstrateseveredisparityinincomelevels,healthservicesandhealthoutcomes.
AlthoughKingCountyisoneofthewealthiestregionsinthecountry,SeaTac/Tukwila

hastwiceasmanypeoplelivingbelowthefederalpovertylineandfarhighermortality
ratesthantherestofKingCounty.ArecentsurveyintheTukwilaSchoolDistrictfound
that17%ofallkindergartenstudentsinthedistrictarehomeless(G2L:GlobaltoLocal
2013).RatesofpovertyaresignificantlyhigherinSeaTacwhenmeasuredagainstthe
KingCountyaveragethemedianincomeis29%belowthecountywidemedian,and
givendatacollectedbetween20062010,2247%ofresidentslivebelow200%ofthe
povertyline,whileunemploymentcontinuestohoverataround10%(Felt2013).
AccordingtoarecentreportfromBrownUniversityonthestateofracialandethnic
diversityinAmerica,Tukwilaisthe11thmostdiversecityintheUnitedStates,SeaTac,
the15th(Balk2012).Between20052009,thepercentofthecountypopulation
identifyingasforeignborngrewto19.7%;inSouthKingCounty,themajorityoffirst
generationimmigrantsidentifyasrefugees(Felt2012).
Healthproblemsidentifiedbythecommunityincludelimitedeconomic
opportunities,languageandculturalbarriers,difficultynavigatingthehealthandsocial
servicesystem,andalimitedsensethatpeoplecantakecontrolovertheirlives(G2L:
GlobaltoLocal2013).Lifeexpectancyhoversat80.4,whilecomparatively,West
Bellevuehasanexpectancyof86.2;17%ofSeaTac/Tukwilaresidencehavebeen
reportedashavingpoorhealth,thisnumberisoverthreetimeshigherthaninBellevue.
Whiletheseaveragesarecomparativelyhighwhenmeasuredagainstnationaloutcomes,
a6yeardeviationinlifeexpectancybetweencitiesonlymilesapartisconcerning.
Maternalandchildhealthstatisticsaresomeofthelowestinthecounty,asareratesof
accesstopreventativecareandservices(PublicHealthSeattleKingCounty2014).

WhoareCommunityHealthWorkers?
CHWsdonotprovideclinicalcareortreatment,nordotheyreplacepositions
traditionallyheldwithinthehealthcarecommunitytheyareasupplementtothe
biomedicalizedsystemofcarethathasbecomethestatusquo,andtheirnumbersareon
therise(GoodwinandTobler2008).Themostessentialcomponenttothesuccessof
CHWsistheirstatusasindigenousandrespectedmembersofthecommunityoffocus,in
thiscase,theextremelydiverseandunderservedcommunitiesofSeaTacandTukwila.
CHWsareessentialinbreakingdownlanguage,ethnic,andculturalbarrierswhichhave
historicallycausedthemostdamagetothequalityoftreatmentfordisenfranchised
groups(GoodwinandTobler2008).Byhavingsharedcertainlifeexperiencesand
socioeconomicrealitieswithclients,CHWsaremuchmoreeffectivelyabletoadvocate
forpatientshealthneeds,andcommunicatethecomplexitiesofanoftenintimidatingand
complexmedicalinstitutionandhealthinsurancesystem.PrimarydutiesofCHWsvary
greatlydependingontheCHWsprogramandlocation,aswellastheindividuals
personalskillset.CHWsaremostcommonlyutilizedintheUSinsituationswherethey
mayprovidethedualservicesofbothalanguageandculturalinterpreter.Situations
involvingfirstgenerationimmigrants,refugees,andcommunitieswithspecialneedsare
citedbydoctorsasparticularlyindemandofCHWs(CriticalLinks:CommunityHealth
Workers2009).Promotinghealtheducationinyoungpeople,providingcounselingin
healthylivingpractices,andprovidingindirectcommunicationandsupportinconnecting
clientswithhealthcareservices,navigatinggovernmentaidprograms,andproviding

transportationtoandfromhealthclinicsareallindispensabletotheCHWsdynamicjob
description(Perry1997).
WhiletheutilizationofCHWsinanyofficialcapacityisarecentdevelopment,
therehasbeentremendous,ifnotunanimoussupportamonghealthcareprovidersasto
theindispensablenatureofCHWstothemedicalteam.DidiFarmer,Directorofthe
CommunityHealthProgramforPartnersinHealthRwandaadvocatesforCHWsasthe
mostvaluablecomponentofastrategytoextendprimaryhealthservicestorural
communities(ImprovingOutcomesWithCommunityHealthWorkers2007);Assistant
ChiefSurgeon,USDepartmentofHealthandHumanServices,Dr.JamesGalloway
describesCHWsasthemostessentialcomponentofthehealthteam,secondonlytothe
patient(TheImportanceofCommunityHealthWorkers2012);Dr.BacharaChouair,the
ChicagoDepartmentofPublicHealthCommissionerclaimsthatcertificationofCHWs
isinintegralpartofcreatingasustainablehealthsystemthataddressesgrowinghealth
disparities(TheImportanceofCommunityHealthWorkers2012).Publicsupportersof
CHWsinthemedicalspherearevocal,andgrowinginnumberthissupportisbeing
validated,inpart,byCHWsabilitytoimprovehealthoutcomeswhilesimultaneously
loweringhealthcosts.ForeverydollarinvestedinaCHWintheUS,providerson
averageavoid$13$15inacutecarecosts(TheImportanceofCommunityHealth
Workers2012).Thisisanunprecedentedrateofreturn,andislargelyduetothe
preventativecareandcounselingprovidedbyCHWs.Asatangibleexample,oneofthe
firstASLfluentCHWstoworkoutofMinnesotawasabletoprovidevaluableassistance
toadeaffamily;thisfamilyhadbeenusingthelocalEmergencyRoomfacilityforallof

theirmedicaltheirneedsevenminorconcerns.Thefamilydidthisbecauseoftherare
ASLmedicalinterpreteratthisER.TheirhearingimpairedCHWwasabletoassistthem
infindingalocalprimaryhealthclinicthatcouldfacilitatetheirneeds,whileavoidingthe
devastatingcostsofEmergencyRoomvisits(CriticalLinks:CommunityHealthWorkers
2009).Wherefamiliessuchasthesetypicallytendtofallthroughthecracks,thepersonal
componentandintimatelevelofcommunicationbetweenCHWsandtheirpatients
providesasocialsafetynetwhichhasprovenincreasinglyefficientinitsreductionof
primarycarecosts.
CriticismsofCHWprogramsarenotnonexistent,butcritiquesconsistentlyfall
underagenerallackoffunding,orlackofsufficientresourcestomeetcrushingdemand.
CHWprogramshavebeenunjustlyburdenedasthepanaceaforunderservedand
overwhelmedhealthsystems(SandersandLehmann2007).Theyareneitheracureall
forourfundamentallyweakmedicalstructure,noraremedyforextremestructural
violenceandpoverty.CHWprogramsarenottobeheldresponsibleforgroundup
reform,andshouldnotberegardedbyacapitalistsystemassuch.Community
mobilizationeffortsare,additionally,anessentialcomponenttotheeffectivenessofthe
healthteamparadigm.Withsustainedcommunityparticipationbeingtheultimategoal,
thechallengeofnormalizingcommunityparticipationrequiresgovernmentandnon
clinicalsupport(SandersandLehmann2007).Itcannotbeoveremphasizedthatwithout
sufficientandsustainedsupport,CHWprogramswillinevitablystruggleandfailtomeet
potentialcarestandards.

GlobaltoLocal,withitsemphasisoncommunitybaseddevelopment,has
repeatedlyshownawarenessofboththeneedandrequiredsupportofcommunityhealth
workersintheirSeaTac/Tukwilainitiative.GlobaltoLocalcurrentlyemploys5
communityhealthworkers,targetingincreasedcommunicationandpositiveinteraction
withSomali,Burmese,Latino,andEastAfricanpopulationswithinthecommunity(G2L:
GlobaltoLocal2013).
BroadResearchObjective
Theprimaryobjectiveofmyresearchistodocumentthepreciseroleandfunction
ofCHWsinSouthKingCounty,andtodeterminethecapacityforCHWstoincrease
understanding,navigationandaccessbetweenpatientsandhealthcaresystemsin
SeaTac,KingCounty.
SpecificAims
Inconductingthisresearch,IamtoprovideacritiqueandanalysisoftheGlobal
toLocalinitiative,andwillprovidearecommendationastothepotentialutilizationof
CHWsinthereconstructionoftheUSPublicHealthSystem
Hypothesis
CommunityHealthWorkershaveauniqueandpotentiallyrevolutionaryrolein
providingabridgebetweenthecommunityandthehospital.IntegrationofCHWsinto
thehealthcaresystemhasthepotentialcapacitytoseriouslyaddressmajorissuesof
access,preventativecare,andculturalbarriersinhealthcaresettingsacrossthecountry.

ResearchQuestions

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1. HowdoestheCHWmodel,developedbyaGlobalHealthframework,functionin
adomesticcommunitydefinedbydiverseimmigrantandrefugeepopulations,
highratesofpoverty,anddiversehealthoutcomes?
2. HowdoesthisCHWmodelfunctionasaresourceofnavigationalassistanceto
theUSPH/hospitalsystem?Isthismodelversatile?

LiteratureReview
LiteratureReview:ACriticalAnthropologicalUnderstandingof
Community,Health,anditsWorkers

Forthepurposeofpositioningthisresearchinthefieldofcriticalmedicalanthropology
andglobalhealthliterature,IwilladdresstheCommunity,Health,andWorkers;the
conceptualunderstandingoftheseideaswillactasthetheoreticalframeworkofmy
research.

Community

RedefiningaUnderStudiedandOverAppliedTerm
Communityhealthanddevelopmentdiscoursehasbeenacornerstoneofglobal
andpublichealthworkfordecades;itisconsideredbymanytobeoneofthe
foundationalpillarsofthefieldofmedicalanthropology.Publichealthcaremarksa

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movementtodecentralizetheinstitutionoftheUShealthsystemtoincludeamore
dynamichealthinfrastructure;healthprograms,includingthoseinitiatedbyGlobalto
Local,aredesignedtodependoncommunityparticipation,developmentandpolicy.The
KingCountyPublicHealthDepartmenthasrecentlyrefocuseditseffortsonthis
communitydevelopmentapproach,makingitparticularlyrelevantinthiscontext
(HealthStatusandHealthSystemsProject(KingCountyetal.1997).VeryfewPHC
programshavecriticallyexaminedlocalculturaldefinitionsofcommunityandinclusion
however,oftenassumingcohesionbasedongeographicproximity,socioeconomic,or
racialsimilarities(CoralWaylandandJeromeCrowder2002:231).Intheirreviewof
relevanthealthliterature,JewkesandMurcottreportthatthereisasingularlackof
specificityandagreementregardingtheconstructofcommunity(JewkesandMurcott
1996).
TheWHOdefinitionofcommunityisoutlinedbythreegeneraldefinitionsof
special,socialandpoliticalsimilarities(DeclarationofAlmaAta1978).Shared
characteristicsofapopulationareoftenassumedtoimplysharedhealthproblems,
concern,andinitiativeincollectivelyfixingtheseprograms;anthropologicalstudyhas
proventhistheoryinsufficient.Assumptionsofcooperationhaveprovenfataltomany
publichealthandCHWinitiatives.Similaritiesinsocioeconomicstatus,race,or
geographymayinsomecircumstancesacttodisuniteneighborhoods,ratherthancreate
anenvironmentdefinedbysolidarity;severalstudieshaveshownthatstresshasbeen
proventoexacerbatethiscommunalfragmentation,wheredifferencesincitizenship

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status,personalhistories,orinternalizeddiscriminationmayacttocausefissionswithin
groups(RifkinandWorldHealthOrganization1990).
TheBrazilianMinistryofHealthestablishedanationalCHWInitiativein1993
(PACS);whilethisprogramwasdesignedwiththeintentionofextendingPHCto
pregnantwomenandchildrenundertheageoffiveinlowincomeneighborhoods,its
potentialefficacyhasyettocometofruition.ThoughCHWslivedinthesame
geographicspaceandsharedsimilardemographicstatuswithmanyoftheirpatients,
extensiveinterviewsconductedbythePACSprogramrevealedthatcommunitymembers
wereoftenhighlymobile,viewedCHWsasstrangers,andactivelyavoidedinteraction
duringhomevisitsmanyconsideredintrusive(CoralWaylandandJeromeCrowder
2002).Asstatedabove,similaritiesinethnicorculturalidentitiesdonotimmediately
translateintotrustrelationships.
InstudyingheathaccessandcommunityhealthwithintheSeaTacdistrict,itwill
beabsolutelyessentialtoadaptthiscriticalmedicalanthropologylens;asanareadefined
byitsheterogeneouspopulation,localdefinitionsandexperiencesofcommunitywillbe
studiedandutilizedinmyresearch.

Workers

Indiscussingwhatitmeanstobeacommunityhealthworker,twogenericbodies
ofliteraturearediscussed.Thefirstiscomprisedofbiomedicalandpublichealthstudies
whichultimatelydemonstratetheeffectivenessandefficacyofCHWsinavarietyof

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settings(Bowseretal.2015;TaylorandSambrook2012;Walt1988;Herman2011;
Najafizada,Labont,andBourgeault2014;Sprague2012;GarciaandGrant2015;
RobertaD.Baeretal.2004;GlobaltoLocalLandscapeAnalysis:LessonsLearnedfrom
GlobalHealthProgramsn.d.;TsaiandLee2015).Thesecondbodyofliterature,
providedbyanthropologicaltheory,analyzesthefunctionofCHWsinoccupyingthe
uniquespacebetweenbiomedicalandinformalhealthsystemsutilizedbythecommunity.
Ifocushereonthetheoryandcritiqueprovidedbymedicalanthropologists,astheory
bestequippedtoprovideandexplanatorymodelforexperienceofCHWsatGlobalto
Local.
Thoughrecentpublichealthtrendshaveworkedtomovecarebeyondthewallsof
thehospitalandintothecommunity,itisimportanttounderstandthetheoreticalspace
fromandintowhichhealthisbeingdefined.Theworkofmedicalanthropologistsbeyond
theedgesoftheformalcaresystemhasbeguntoexpandtheclinicallyacceptedscopeof
recognizedhealthpractices(Madden2015).Thisisparticularlycrucialwhendiscussing
immigrantandrefugeepopulations,suchasthoseinSeaTac;uninsuredstatus,cultural
andlinguisticbarriers,aswellasuniquementalandphysicalhealthrisksofimmigrants
andrefugeesoftenpushpatientsoutsideoftherecognizedsphereofcare.Anthropologist
ErinMaddenutilizesthetheoreticalframeworkofculturalcapitalandcriticalracetheory
toexplainsystemsofhealthcareexclusion;IexpandthismodelnowtodefineCHWs,
andtheiruniquepositionastranslatorsbetweencontrastingformsofcapital.

CommunityHealthWorkers:ConvertingCulturalHealthCapital

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CommunitiesstrugglingwithaccesstohealthcareintheUSareoftendefinedby
disadvantagedpositionsofsocioeconomicstatus,race,andcitizenshipstatus.Theterm
healthcareincludesalargedomainofcarepracticesandnarrativeswhichexistoutside
oftheformalcaresphererecognizedbytheinsuredUSpopulation.Thetheoretical
frameworkofCulturalHealthCapitalprovidedbymedicalanthropologistsallowsusto
understandtheculturalresources,skills,andknowledgeutilizedandexchangedby
marginalizedcommunitieswhennavigatingstructuraloppressioninhealthcare(Madden
2015;Shim2010).
Theoriesofcapitalhavetraditionallybeenusedtodescribeeconomicandpolitical
resourcesnecessarytonavigatedominantsociety,andgiventhecapitaliststructureofthe
UShealthcaresystem,thesetheoriesbecomeparticularlyrelevant(Richardson1986:248
251).JanetShimproposestheutilizationofCulturalHealthCapital(CHC)asatheoryto
describetheassetsusedbypeopletonavigatehealthcareinallofitsforms;formsof
CHCincludeknowledgeofbiomedicineandvocabulary,anabilitytotakeanobjectand
instrumentalviewofonesownbody,andanabilitytocommunicatesocialprivilege
(Shim2010:3).CHCnecessarilymapsontopoliticalandeconomichierarchies,andare
intertwinedwithrealitiesofrace,gender,andcitizenshipstatusdefinedincriticalrace
theory(DelgadoandStefancic2001).
CHWsactasculturalliaisonsbetweenformalmedicalcultureandthelocal,or
communityhealthsphere,astypicallyembodiedinthephysicianpatientinteraction.
CHWsoccupyauniquepositionorresponsibilityinconverting,translating,and

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exchangingformsofCHCsothattheyareunderstoodanappreciatedbymembers
occupyingbothspaces.

AUniqueAppreciationforCulturalCompetency
InconductinginitialgroundresearchfortheGlobaltoLocalinitiative,Ifound
myselfconversingwithoneofthevolunteeroutreachdeskoperativesconnectedtothe
G2LcollaborativeHealthpointclinic;shespokeverycandidlyofherwork,statingthat
anyonecanbeculturallycompetentthismeansnothing;ittakesmorethanthattowork
withinthiscommunity.FromthisconversationIwascompelledtoexpand;ascultural
competencyisatermutilizedinthisconversationofmedicaltranslationandminority
heath,Iwillunpackithere.
Culturalcompetencyhasbeenafocusofmedicalanthropologicalresearchsince
theinceptionofthefield;onlyrecentlyhoweverhasthisconceptbeenrecognizedbeyond
itsformalroleofsuperficialanecdotebythebiomedicalcommunity.Theabilityto
appropriatelynavigateamultitudeofdisenfranchisedpatientgroupshasbecome
respectedasanecessaryelementforimprovinghealthoutcomesandservicesamonga
growinglydiversepopulation(Lamianietal.2012).Unfortunately,intargetingmedical
professionalsabilitytopracticeculturalcompetency,thepropagationofracialand
ethnicstereotypesviaculturalcompetencymanualshasbecomethenorm(Smith
Morris2014:33).FourhourcoursesonculturalnormsamongLatinomigrant
communities,Sudaneserefugeecommunities,orsimilardeviantpopulationshas
becomestandard(36).Ananthropologyofthesepracticesofbiomedicalcultural

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competencydiscourseshasprovidedconvincingevidencethatculturalcompetency
demandsmorethansuperficialormechanisticunderstandingofculturalnorms,language,
orhistories;studiesshowthatcompetencyinthissensedemandscommunityinvolvement
andcrossculturalinteractionbeyondthebiomedicalsphere.Competencydemandsa
redefinition,orexpansionofunderstandingofculturalhealthcapital(Kripalanietal.
2006).CHWshavethenecessaryskillsrequiredtoadequatelybridgethisgapbetween
biomedicalandcommunityculture,astheyhavethecapacitytotranslatethiscultural
healthcapitalfromthebiotothesocialform.
ExpandingCHWPrograms
IndiscussingthepotentialexpansionorpermanentintegrationofCHWsintothe
UShealthcaresystemsstandardizedmedicalteam,severalrelevantchallengescome
intoplay.ParticularlyinlightoftheAffordableCareAct,researchhasbegun
surroundingthestandardizationofCHWprograms,theirintegrationintothepublichealth
system,guidelinesforcompensation,anddiversityofpopulationssettings(Garciaand
Grant2015).ThoughCHWprogramshavebeenimplementedthoughinitiativestargeting
relativelyconcentratedhomogenouspopulations,littletonoresearchhasbeenconducted
ontheirefficacyinadiverse,dynamicsetting.

Health

Internationalpoliticaldiscourseisdominatedtodaybyhumanrightsideologies;
withinthemedicaldomain,ahumanrighttohealthsetsthedefinitionofhealthitself

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underextremescrutiny.TheWHOdefinitionofhealthisfrequentlyreferencedasa
rubric:Healthisastateofcompletephysical,mentalandsocialwellbeingandnot
merelytheabsenceofdiseaseorinfirmity(WHO|ReDefiningHealthn.d.).This
definition,thoughcritiquedforisvagueandunattainablescopebysome,doesprovidea
valuabletemplatefromwhichtodiscusshealthinthecontextofmyresearch.
MedicalAnthropologyisuniqueinthatitcontributestopublichealththesocial
counterweighttothebiomedicalstandardofphysicalandmentalhealth.Instudyinga
communitydefinedbydiversepopulationsofimmigrant,refugee,andlowincome
demographics,includingatheoreticalframeworkforhealthdefinedbyoverarching
theoriesofstructuralviolence,criticalracetheory,andpatient/providerpowerdynamics
isabsolutelyessential.
PaulFarmer,recognizedtodayasoneofthemostinfluentialfiguresinthefieldof
MedicalAnthropology,outlinesabiosocialapproachtohealthwithavisionand
enthusiasmprovencontagious.Astheauthorwhofirstinspiredmyintroductionto
anthropologyasanaccesspointformedicalhumanitarianism,Iwillusehisworkto
definehealthinthiscontext.Criticalmedicalanthropologyandglobalhealthprovidesan
interdisciplinaryapproachtotheanalysisofhealththattravelsfarupstreamfromthe
healthoutcomesassessedintheclinicalsetting.Farmerhighlightstheseresocializing
disciplinesasanthropology,sociology,history,andpoliticaleconomytoconstructthe
socialtheorythatoutlinestheforcesthatlargelydeterminepopulationhealth.Indefining
healthforthisanthropologicalstudyofcareaccessintheSeaTac,KingCountythe
proceedingtermsmustnecessarilybedefined

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Health:ABiosocialApproach
Abiosocialapproachtohealthisbuiltuponthetheorythatthebiologicalcauses
ofdiseaseaddressedintheclinicalsettingareinfluencedbysociety,politicaleconomy,
history,andculture;illhealththerefore,isbestunderstoodandtreatedbyaddressingthe
interactionofboththebiologicalaswellassocialprocessconstructingthehealth
narrativesofpatientsandpopulations(Farmer2013:17).Whilethebiologicalcomponent
ofhealthislargelyrepresentedinthisstudybytheformalclinicalsettingoftheUShealth
system,thesocialfactorsinfluencinghealthprimarilyaccesstohealthcare,willbethe
focusofmystudy.
HealthandStructuralViolence

StructuralviolenceisatermfirstcoinedbyJohanGaltung,anddescribessocial
structureseconomic,political,legal,religious,andculturalthatstopindividuals,
groups,andsocietiesfromreachingtheirfullpotential(Galtung1969:167191).Violence
isutilizedheretoconveytheappropriateimageofavoidableimpairmentofhumanlife,
whichlowerstheactualdegreetowhichsomeoneisabletomeettheirneedsbelowthat
whichwouldotherwisebepossible(Farmeretal.2006).Structuralviolenceisoften
embeddedinlongstanding,ubiquitoussocialstructuresandinstitutions.Disparateaccess
toresources,politicalpower,education,andhealthcarehavebecomenormalizedin
institutionswhichperpetuatesocialforcesofdiscrimination(Gilligan1997).Theideaof
structuralviolenceislinkedverycloselytosocialinjusticeandthesocialmachineryof

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oppressionamajorthemeinmyresearchwhendiscussingaccesstohealthcareinthe
minorityimmigrant,refugee,andlowerincomecommunitiesservicedbytheGlobalto
Localprogram.

ProposedResearchMethods

ANoteonMethodologies
MypositionasacommunityoutsiderinthecontextoftheSeaTacpopulation
providesmewithbothadditionalchallengesandinsightinmyresearchprocess.Asan
outsiderIwillbemorecriticallyawareofnotmerelythesimilarities,butthedifferences
withininteractingspacesoffocus.Myacademictrainingasbothapremedicaland
medicalanthropologystudentwillaidinmynavigationbetweenbioandsocialspacesin
thisenvironment.Inordertoovercomepotentialblindspotsduetomyoutsidethebox
status,IwillbeginmytrainingasaGlobaltoLocalvolunteerduringthesummerof2015.
Asemphasizedbyanthropologymethodologyliterature,itisabsolutelyessential
toacknowledgeandactivelyworktoovercometraditionalpowerdynamicsimposedby
researcher/subject,physician/patient,andprivileged/minoritystatus.Whilemanyinthe
fieldrefertothisawarenessaspartofafeministideologicalviewpoint,Iwillrefertoit
hereasanactiveefforttorelaycommonhumandecencyandculturalawareness.Someof
themethodsIintendtousetodeconstructthesepowerdynamicsincludemeetingwith
intervieweesoutsideofthemedicalsettinginalocationoftheirchoice,employing
myselfasavolunteerinacustomerservicepositionwithinthecommunity,and

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structuringmyresearchandinterviewquestionsinsuchawayastobeparticipantdriven
andled.

Methods
InconductingmyresearchIwillutilizefourprimaryanthropologicalmethods.
Thesemethodswillinclude1)participantobservation2)semistructuredinterviews3)
shadowing4)literaturereview.Thesemethodswillallowmetobecomeintimately
involvedandnecessarilyimmersedintheGlobaltoLocalprogrammypointofaccess
totheSeaTaccommunityforthedurationofthisstudy.

1)BeginninginJuneof2015,IwillbeginmytrainingasavolunteerattheGlobalto
LocalConnectionDesk.ThisdeskoperatesasaprimarypointofaccessforSeaTac
communitymembersseekingassistanceandcarethroughthelocallyutilizedHealthpoint
Clinic.VolunteersattheG2LConnectionDeskbelongtoadiversesetoflocal
communities,andidentifyasPublicandGlobalHealthstudentsattheUniversityof
WashingtonandSeattleUniversitycampuses.Ihavepersonallyspokenwithandinitiated
contactwithvolunteerswhoidentifyasmembersofthelocalHispaniccommunity,Iraqi
andAfghanimmigrantcommunity,andSudanesecommunityatGlobaltoLocal.
Iwillcollectobservationaldataandnarrativesduringmyfieldresearch(participant
observation,shadowing,andinterviewmethodologies).

21

2)Iwillconductsemistructuredinterviewswithinvolvedpersonsonalllevelsofthe
GlobaltoLocalinitiative.Iamcurrentlyincontactwiththefounderoftheinitiative,the
volunteerdeskcoordinator,andtheCHWprogramcoordinator.Iwillconductinterviews
withthesixCHWscurrentlyemployedbytheGlobaltoLocalprogram.Iplanon
gainingaccesstoadiversewebofaffiliatedcommunityhealthprofessionalsandlocal
activiststhroughthesnowballmethod,givenmyalreadyestablishedcontacts.By
utilizingthissocialwebIwilldevelopamultifacetedunderstandingoftheGlobalto
LocalprogramSeaTaccommunitywhichitserves.
Iwillanalyzedatacollectedfromtheseinterviewsusingaxialcoding.This
methodwillbeusefulwhenintegratingmaterialfromparticipantobservation,asits
inclusionofthematicmappingwillallowmetovisuallyidentifymajorthematic
componentsoftherolesandpracticeofCHWsatGlobaltoLocal,theirpositionwithin
theorganizationandlocalhealthsystem,andthespacesandlocallydefinedcommunity
structure.

3)AsapremedicalstudentIhavecultivatedseveralpointsofaccesswithphysiciansand
medicalstaffattheHealthpointandHarborviewclinicsbelongingtotheGlobaltoLocal
collaborative;IhaveattainedpermissiontoshadowMDsandsocialworkersinKing
County.Shadowingintheclinicalsettingwillallowmetoconstructamultidimensional
understandingofallpointsofaccesstohealthcareintheSeaTaccommunity,asan
analysisofCHWsintheirrolesofbridgingthegapbetweenhealthcareprovidersand
communitywillrequireanunderstandingofbothspaces.

22

4)Alargeanddiversecollectionofmaterialsareavailabletoassistimmigrant
populationsinnavigatingpopularcultureandtheAmericanhealthsystem.Similarly,
particularlyduetotherecentAffordableCareActinformationcampaign,servicesare
similarlyavailabletothegeneralpublic.Inreviewingthesetwobodiesofmaterial,there
aresubstantialdifferencesinthetypesandqualityofinformationprovided,asorganized
bytargetaudience.Ananalysisandcriticofthesemajorsimilaritiesanddifferenceswill
providevaluableinsightintopopularinterpretationsofculturalheathcapital,and
institutionsofsocial,politicalandeconomicviolence;whileIwillbeunableto
functionallytranslatenonenglishdata,givenmyinitialreview,versionsofalmostall
materialshavebeendesignedforEnglishspeaks,andEnglishfluencyisoften
mandatoryforcitizenshipstatusattainmentandtheformalintegrationprocess.

ConclusionsandSignificance

Wearenowatapivotalmomentinthehistoryofhealthcare.Whilegrowing
demandforuniversalhealthcareaccessandequalityistakingcenterstagethe
internationalanddomesticpoliticalarena,acoordinatedstrategytoaddressgrowing
disparitiesinhealthhasyettobedeveloped.TheUnitedStates,agloballeaderin
healthcare,findsitselfinthemidstofamedicalrevolution.Ithasbeenwidelyaccepted
bythehealthcommunitythatthemedicalsysteminplaceisnolongerfunctionalunable
tofluidlyaddressanincreasinglydiversepopulationofneed,amajordysfunctionhas

23

becomeapparentthroughoutunderservedcommunitiesacrossthecountry.Radical
disparitiesinhealthoutcomeshavebecomeincreasinglystark,rivalingconditionsin
someoftheworldsmostcriticalthirdworldstates.Physiciansandhealthcare
providers,frustratedbytheinabilityofthecurrentmedicalstructuretobridgecultural
andsocioeconomicbarriersinaccessandcare,arelookingbeyondthetraditionalscope
ofthewesternizedmedicalinstitution.Thisattempttosynccommunityneedand
providedcareisarevolutionarymovement;asaglobalsuperpowerandleaderin
healthcaretechnologies,theUSplaysavitalroleinthedevelopmentofaglobalhealth
careinitiative.
Thisfocusonlocallyappropriatestrategiestobuildingrelationshipsbetween
communitieswiththeirlocalhealthsystempavesthewayforthereformationofthe
futureofinstitutionalizedmedicineanditsrequiredstructuraladjustment.Withthe
effectsofglobalizationredefiningourtraditionalviewsoftheworldandtheboundaries
withinit,theconceptofemployingglobalhealthpracticestoimprovehealthstandardsis
thefuture.Forthefirsttimeinthehistoryofhealthcare,GlobalHealthstrategiesmost
prominentlydiscussedhereasCHWinitiativesarebeingdirectlyappliedtooneofthe
mostdiversepopulationsintheworld;theresultingmodeldevelopedfromthisinitiative
willpotentiallyserveasatemplatefortheexpansionofacoordinatedinternational
medicalstructure.
WhiletheimplementationofGlobalHealthstrategiesonthedomesticfrontis
bothnewandunderstudied,theinitiativethatisG2Lpresentsaparticularlyunique
opportunityforresearch.TheextremediversityfoundinSeaTac/Tukwilaissignificantly

24

higherthananythingfoundinprojectsorstudieseverbeforeinitiatedinthefieldof
GlobalHealth(ImprovingOutcomesWithCommunityHealthWorkers2007).These
strategies,whileproveneffectiveacrossawiderangeofpopulationsandculturalgroups,
haveneverbeenfocusedorutilizedinanefforttoimprovehealthstandardstosucha
diverse,domesticcommunity.Furtherstudyonthenewandbuildingforceofthe
movementGlobaltoLocalrepresentsisabsolutelynecessary.

Timeline
MarchJune2015Anthropology399course;Projectproposalfinalized,
literaturereviewinitiated,GlobaltoLocalVolunteerDeskcompleted,initialcontactsat
GlobaltoLocalandaffiliatedclinicsmade,informalinterviewprocessstarted
July/August2015BeginLiteratureReviewresearchprocess;conductsignificant
reviewofhealthaccessresourceinSeaTac/Tukwila;initiateshadowingcontacts
September2015BeginOrientationandVolunteerWorkatGlobaltoLocal
VolunteerDesk;continueshadowingprocessandobservations
October2015ContinueShadowingandVolunteerprocess,beginconducting
interviewswithGlobaltoLocalStaff;attendadditionalparticipantobservationwork
throughGlobaltoLocal
November2015ContinueShadowingandVolunteerprocess,beginconducting
interviewswithGlobaltoLocalCommunityHealthWorkers;attendadditional
participantobservationworkthroughGlobaltoLocal

25

December2015Beginwrappingupinterviewprocess;moveforwardwith
observationandvolunteeropportunities;discussanalysisprocessmovingforwardwith
advisor,integrateliteraturereviewprocess
January2016Begincodinganddataanalysisprocess
February2016Continuecodinganddataanalysisprocess
March2016finalizedataanalysisprocess;beginfinalprojectwriteup;submit
initialworktoappropriateGlobaltoLocalandUniversityofWashingtonadvisorsfor
review
April2016ANTH491;continuefinalprojectwriteup
May2016ANTH491;finalizefinalprojectwriteup,presentResearchat
UndergraduateResearchSymposium
June2016ANTH491;seekpotentialpublicationopportunities

ResearchEthics
StatementonEthics

Inaddressingtheissuesandspecificmethodologiestailoredtoaddressethical
concernsbornfrommyresearch,IwillusethegeneralrubricprovidedbytheBelmont
Report,asitoutlinesthebasicethicalprinciplesidentifiedbytheNationalCommission
fortheProtectionofHumanSubjectsofBiomedicalandBehavioralResearch.In
systematicallyaddressingtheseconcerns,Iwillspeaktoallpotentialethicalconcerns

26

regardingrespectofpersons,beneficence,andjusticeassociatedwithmyfieldworkand
analysis(USDepartmentofHealthServices1979).
InformedConsent
Iwillexplicitlyaddressinformedconsentthroughoutallmethodsinitiatedinthe
field.InapplyingformyvolunteerpositionatGlobaltoLocal,Ihavespokenwiththe
DirectorofVolunteersregardingmyresearch,andhavediscussedmyproposedresearch
questionsonmyapplication,tobereviewedbytheGlobaltoLocalVolunteerDesk
directors.IwillvocalizemyintentionstoallGlobaltoLocalpeersandstaffwithwhomI
amincontact.
Iwillrequiredirectpermissionbyallintervieweesandshadowingpersonnelto
includetheirthoughtsandaffiliationsinmyanalysis.
AssessmentofRisksandBenefits
Seriousriskofpsychologicalharm,physicalharm,socialharm,and/oreconomic
harmareextremelyminimal,giventhenatureandpurposeofmyworkasananalysisof
CommunityHealthWorkerfunction.IhaveinterviewedGlobaltoLocalemployees
regardingthisissue,andnomajorconcernsarose.
Legalharmwillbetheprimaryriskassociatedwiththisresearch,asseveral
membersoftheSeaTacandTukwilacommunitiesidentifyasimmigrantslivinginthis
countrywithoutUSlegalpermission.Iwilladdressthisconcernwithaconfidentiality
statementallinformationIgatherbothformallyandinformallythroughoutmyresearch
willbeconsideredentirelyconfidential;publicationofsuchinformationwillnottake
placewithouttheproperpermissionandunderstandingofallpersonsinvolved.Iwilluse

27

pseudonymsforallresearchsubjects,whoseidentitieswillbedissociatedfromthe
researchuponcompletion,bymyself.IwillsubmitmyresearchforreviewtotheGlobal
toLocalprogrampriortopublication;asanassociationdirectlyinvolvedinthehealth
managementandlegalprotectionofallSeaTacandTukwilacommunitymembers,this
reviewsourcewillbeextremelythoroughasafinalformofriskassessment.
SelectionofSubjects
Twoprimaryconcernsarisefromtheselectionofsubjectsinthisresearch:1)the
individualselectionofsubjects,andtheintentionalorindirectselectionofsubjectsbased
onpersonalbias,2)thesocialselectionofsubjectsinassociationtoconcernsof
vulnerablepopulationsandresearchpowerdynamics.Iwilladdressbothconcernsinthis
work.
Theprimaryconcernregardingselectionbiaswill,inthisresearch,bethe
navigationofcommunicationbarriers.TheSeaTacandTukwilacommunitiesarehometo
adiversepopulationofethnicandculturalgroups,whoutilizeover20languages(Felt
2012).AsaprimaryEnglishspeaker,Iwillbeunabletodirectlycommunicatewith
communitymemberswhodonotspeakEnglish.Inanefforttoeliminatethisbias,aswell
asotherpotentialpointsofethicalconcernregardinglanguage,race,andcitizenship
powerdynamics,Iwillnotbedirectlyinvolvingnonhealthservicecommunitymembers
orpatientsinmyintervieworobservationwork.
CommunityHealthWorkers,andemployeesofGlobaltoLocal,are
predominantlyfemale.Irecognizethegenderdynamicsatplayhere,andasawoman

28

myselfwillactivelyattempttoexplorethissourceofthisgenderbias.Iwillengagewith
bothfemaleandmalesubjects.
Concernsarisingfromthesocialselectionofsubjectsmostprominentlyrevolve
aroundthepowerdynamicsaffiliatedwithclass,race,andcitizenshipstatus.Iopenly
identifymyselfhereasauniversityeducated,Caucasianfemale.Iwillattempttoaddress
andnegateanysubjectvulnerabilitiesbyconductingallinterviewsatatimeandlocation
selectedbytheinterviewee.Iamconductingallfieldworkwithinthecommunity,atthe
GlobaltoLocalVolunteerDeskandaffiliatedsitesfamiliartocommunitymembers
involved.
FinalRemarks
Anthropologicalresearchshouldinallcasesaddressgivingbacktothe
communityasaprimarypurposeofitswork.Mywork,ascanbefurtherreferencedin
myresearchquestionsandSpecificAims,willdothisbyprovidingvaluableinformation
ontheutilizationofhealthpersonneltobetteraddresshealthissuesandriskamong
underservedandhistoricallydisenfranchisedgroupsacrosstheUS.Therecommendations
thatIwillconstructasaresultofthisresearchhavethepotentialtofunctionasa
educationtoolandsystemreferencewhenconsideringtheutilizationofcommunity
healthworkers.
Federalregulationsrequirethatriskstosubjectsbeoutweighedbythesumof
boththeanticipatedbenefittothesubjects,andtheanticipatedbenefittosocietyinthe
formofknowledgetobegainedfromtheresearch.Icansoundlyconclude,upon
reviewingtheprospectiveethicalriskassociatedwithmyresearchmethodologies,that

29

thebenefitofmyresearchcontributionfaroutweighsanyminimalrisk,whichIhave
furtherreducedbydirectlyaddressingallsuchconcernsabove(USDepartmentofHealth
Services1979).

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