Neighbors Who Make House Calls

In the late morning summer swelter, Paige M. Bailey pounds on the white wooden door at 21 Decker Street, one of the few occupied homes in the narrow canyon of dilapidated row houses. The red or neon orange Xs on most doors mark the houses to be gutted and renovated.

A young boy in baggy shorts lets in Bailey. He goes off in search of his older brother. Bailey waits. She wears bright yellow rubber shoes and carries a pink stethoscope. "Johns Hopkins" is stitched in gold thread on one side of her navy blue medical scrubs, while the letters "CHW" and the caduceus symbol emblazon the shirt's other side.

A four-foot stuffed brown dog sits on a couch near the front window. The TV blares a Berenstain Bears cartoon. Without air conditioning, the row house is tropically humid and dizzyingly hot. Eighteen-year-old Bawnso Vonty enters the room, shyly greets Bailey and then leads her upstairs. The teen will translate for Bailey; his grandfather speaks Krahn, a West African language.

A 90-year-old Liberian refugee, Zarkly Vonty sits in a small back room on the second floor. He smiles and nods in Bailey's direction, though he has difficulty seeing her because of the cataracts that cloud his eyes. Bailey is not a doctor or a nurse. She is a community health worker (CHW), part of a Johns Hopkins Urban Health Institute team dedicated to improving the health of people in East Baltimore. Like the team's other CHWs, Bailey has had six weeks of training in physiology, medical terminology, first aid, conflict resolution and other skills. The training has helped her make a dramatic impact on Vonty's health. Before visits by Bailey and another CHW, Vonty didn't eat regularly, was dangerously thin, had high blood pressure and was mostly confined to bed. Initially, the CHWs brought him pureed food that he could eat with his poor teeth. Now, though still frail and near blind with cataracts, Vonty has gained weight, lowered his blood pressure, had successful prostate cancer surgery, and is being scheduled for dental and cataract surgery. "These are stellar impacts that would not have happened had we not been there," says Chris Gibbons, MD, MPH '97, associate director of the Johns Hopkins Urban Health Institute and leader of the seven community health workers on the team.

Near the end of her visit with Zarkly Vonty, Bailey learns that the grandfather hasn't been taking his medications recently.

His blood pressure might be a little high, Bailey warns. Petite with short hair, Bailey carries herself with confident grace. Born and bred in East Baltimore, she's comfortable joking with white construction workers or chatting up African-American mothers sitting on their stoop.

Bailey wraps a blood pressure cuff around Vonty's bicep. When it reads 134 over 77, she says, "Not bad. Not bad, actually." After she learns that the elder Vonty recently missed doctor appointments with his urologist and ophthalmologist, Bailey says she'll help reschedule those. A month earlier, when Vonty had the prostate cancer surgery, Bailey waited at the hospital for 14 hours until she could see him in the recovery room. "I had to look at him myself and make sure he was okay. You know what I mean?" she says.

CHWs like Bailey have long been a part of health programs in developing countries; and they have been part of interdisciplinary research at Hopkins into the prevention and treatment of chronic diseases for decades. Bloomberg School researchers and others hope that CHWs can help people with limited resources surmount the considerable barriers to care: medical insurance, transportation to the doctor's office, the physician's intimidating presence, not to mention the costs of doctor visits, treatments and prescription drugs.

"From the perspective of racial and ethnic minority populations in the U.S., you almost get the sense that many health care systems were built with an approach of 'If we build it, they will come,'" says Jean Ford, an Epidemiology associate professor. Instead, he argues that health care services need to take into account a population's demographic characteristics, its culture and its available resources.

Ford is launching a randomized, controlled trial to determine whether CHWs can help improve cancer detection and treatment among African-American seniors who are Medicare beneficiaries. (African Americans have the highest mortality rates in the U.S. for most cancers.) "The advantage of community health workers is that they know the community, they look like the community and they've experienced a lot of these barriers themselves," says Ford. "The idea is to use community health workers as a means for empowering people to take care of their health by educating them and supporting them to overcome those barriers."

In their previous lives, the CHWs with the Urban Health Institute project worked as teachers, nurse's assistants, school crossing guards or postal workers. Some have diabetes or high blood pressure. Some are recovering drug addicts. The CHWs may not know organic chemistry or how the peristaltic process works, but they do know the people of East Baltimore. They know who's not eating, who's not taking their prescription medications, whose blood pressure is up, who wants help getting off drugs, and who's holding back from their doctor important facts like they can't afford the medications prescribed for them. People confide secrets to CHWs that they would never tell their doctor or a nurse. "I've been in the place of some of these clients we're talking about. I'm here by the grace of God so we can have a healthier and better East Baltimore," says Barbara Johnson, an enthusiastic, older CHW known as "Miss Barbara."