Promoting health — and trust
By Emily Stifler Wolfe, Montana Free Press, October 26, 2020 (Photo Credit: Emily Stifler Wolfe / MTFP)
WEST YELLOWSTONE — Yessika Vega has lived in Montana for 17 years. She left home in Villa López, Chihuahua, Mexico, after high school to learn English in El Paso, Texas, and attend college. That’s where she met her husband, who was born in Idaho to immigrant parents.
“We were supposed to come to West Yellowstone and just work for two summers and save money and go back and buy a house,” said Vega, now 40. Instead, they decided to stay in Montana, and Vega soon became a naturalized citizen. She now has four kids between the ages of 3 and 14 and works in customer service at First Security Bank.
“We like it here,” she said. “It’s a small town, you know everybody.”
Local public school records indicate that 30% of the students enrolled in fall of 2020 are Latino and, anecdotally, the total percentage of Latinos in the town of 1,300 is closer to 40%. Vega said that pre-pandemic, hundreds if not thousands more arrived seasonally to work summer jobs in restaurants and hotels, both in town and in Yellowstone National Park. Many Spanish-speaking people approached Vega regularly for help with things like translating a medical appointment, applying for social services or registering a car.
That’s why the nonprofit medical clinic Community Health Partners brought her on when it launched a promotoras de salud program in 2015. Promotoras — Spanish for “health promoters” — are lay health workers, usually women, trained to advocate for their families and communities through education and outreach.
First developed in mid-20th-century Mexico, the promotora model then spread throughout Latin America and into the U.S., where promotoras have served as liaisons between their own culture and the Western medical system for more than two decades. From Texas to California, in Washington and the Midwest, promotoras address issues including chronic disease, domestic violence, child abuse, mental health and worker rights, helping Latinos navigate the complex, potentially unfamiliar U.S. health care system in the face of a language barrier, lack of insurance and threat of deportation. Some work in institutional health care settings, while many, like Vega, provide services as trusted community members.
For CHP, which provides sliding-fee-scale health, dental and behavioral services through clinics in Bozeman, Belgrade, West Yellowstone and Livingston, the promotora program was a response to a shift in patient demographics.
“All of a sudden [in 2006] we were hearing Spanish being spoken in our waiting rooms almost daily,” said Buck Taylor, CHP’s director of community development and administration, and a co-founder of the promotora program. While Latinos had worked on potato farms and dairies in the Gallatin Valley for a number of years, many more moved to the area during the Big Sky construction boom of the mid-2000s, according to Bridget Kevane, a Latin American and Latino Studies professor at Montana State University, director of MSU’s Liberal Studies program, and co-founder of the promotora program with Taylor.
After conducting focus groups in West Yellowstone and Belgrade in 2015, Taylor and Kevane recruited six volunteers, including Vega, from Gallatin and Park counties. The women received training from health professionals, and then hosted community workshops to discuss topics like nutrition and mental health. They also connected people to doctors, psychologists, health screenings and social services. In 2016, the program received $60,000 in combined funding from the Montana Healthcare Foundation and the Montana State University INBRE (IDeA Network of Biomedical Research Excellence) program funded by the National Institutes of Health.
When that funding ended in 2018, the Gallatin City-County Health Department, which was also actively recruiting bilingual staff, adopted the promotora program. Today, there are three promotoras in West Yellowstone and one in Belgrade. They receive an annual stipend to act as a bridge between the health department and the Latino community. In addition to their advocacy and education work, they have trained to help with the census and work to increase Latino access to the free preventative screenings and immunizations offered by Bozeman Health.
When clusters of coronavirus cases began to emerge in the Latino community in West Yellowstone in late June, the health department hired Vega and another promotora, Ana Nascimento, a teller at First Security Bank, as part-time health department employees. The job is in addition to their regular promotora responsibilities. At the time, they were integral to stopping the spread, said Liz Aghbashian, the department’s health promotion specialist and manager of the promotora program.
Latinos, even those who live and work here legally, can be reluctant to accept medical or social services, according to Randall Caudle, an immigration attorney in Missoula. That includes COVID-19 testing or treatment and unemployment benefits.
Some fear that drawing attention could lead to deportation or harassment for themselves or their loved ones, Caudle said, pointing to ICE-conducted raids in Western Montana in 2018. That same year, two women in Havre were interrogated and detained by Customs and Border Protection because they were speaking Spanish in a convenience store, and the Gallatin County Sheriff made an agreement with ICE this past January that allows his office to hold someone they’ve arrested on criminal charges and suspect of being in the country illegally until ICE arrives. People without documentation may also fear that using medical or social services will prohibit them from acquiring legal immigration status in the future, Caudle said.
But even during a coronavirus outbreak, people still have to feed their families and pay rent. In West Yellowstone, many Latinos work in either the service or construction industry, where paid sick leave isn’t usually an option. Early on, some went to work sick, ignoring quarantine and isolation directives, Aghbashian said. Others who were working illegally sometimes wouldn’t admit to a nurse where they had been, which made contact tracing investigations ineffective.
When it was a promotora on the other end of the line, things were different.
“We are not interested if you’re illegal or not,” said Nascimento, a Brazilian who moved to Big Sky in 2013, and then to West Yellowstone, where her husband had been one of the first Mexican kids to attend school. “We don’t ask that. We just want to help people get healthy.”
After public health nurses completed a contact tracing investigation, Vega and Nascimento made daily calls to anyone in isolation or quarantine, coordinating food and mail deliveries and medical care, helping people apply for rent and utility assistance and unemployment benefits, and making sure they understood the instructions and had the resources to stay home.
Daniela Lopez-Morales, a nurse at the health department who investigated many of the West Yellowstone cases, was born in Mexico and grew up in Colorado. She said that in many cases she was able to develop the rapport needed to do a proper investigation because of her Spanish and cultural fluency, but that the promotoras had still another leg up.
“Because they’re part of the community, the people that were talking to them knew them, so they felt safe to be able to give them the information they needed,” Lopez-Morales said.
For the health department, the promotora connection also meant critical hands on deck.
“They were the ones that kept track of people and kept asking about symptoms after my initial call,” Lopez-Morales said. If something was amiss and they were concerned about anything, [the promotoras] would call me or one of the other nurses for direction.”
Community health workers are becoming more common in Montana and around the country because they’re an affordable, holistic way to improve health outcomes for marginalized populations. With promotoras’ proven track record nationwide and the Gallatin County program’s early success, the model is a culturally appropriate and effective means of supporting the state’s growing Latino population, said MSU’s Kevane, who is still an adviser to the Gallatin promotora program. In the current moment, promotoras can help vulnerable community members who might otherwise avoid coronavirus testing or treatment understand its importance, especially in the face of cultural fears exacerbated by the Trump administration’s anti-immigrant policies.
“We need our patients to know that if there is a need, they can contact us. Sometimes people feel doomed because they don’t know there is a solution. So that’s why we’re there.”
BELGRADE PROMOTORA CHIARA ROSSI
As the number of Gallatin County coronavirus cases rises, including a cluster in West Yellowstone in October, Aghbashian said, the promotoras remain vital to the health department’s efforts to halt the spread through contact tracing.
“I told my manager, ‘Thank God we have the promotoras in West [Yellowstone],’” Aghbashian said. “They’re worth their weight in gold.”
Latinos are the fastest-growing minority population in the country. They make up 18% of the total U.S. population, and are forecast to reach almost 30% by 2060. Of Montana’s million residents, an estimated 4.1% are Latino, which is roughly 43,800 people.
Latinos have been here since before Montana was a state, first as fur traders, cowboys and railroad workers, Kevane said. Starting in 1942, many Latinos came to work in the sugar beet fields of eastern Montana as part of the federal Bracero program, which brought millions of low-paid Mexican laborers to fill U.S. farming labor shortages during WWII. The program ended up lasting more than 20 years, and descendants of those braceros still live in the Billings area today.
Elsewhere in the state, Latinos have found agricultural niches, Kevane said, like the migrant workers who come from Washington every year to pick cherries in the Flathead Valley, the sheep shearers and potato farmers who live year-round near Dillon, and the dairy workers who are a critical part of the milk industry in Manhattan and Amsterdam.
The most concentrated growth, however, has been in Gallatin County, where tourism-related service jobs in West Yellowstone and a booming construction industry in Big Sky and Bozeman have drawn many young families.
They come from Mexico, Honduras, El Salvador, Guatemala, Chile, Peru, Venezuela and other countries, as well as other parts of the U.S.
While it’s impossible to know exactly how many Latinos live in Gallatin County or how quickly the population is growing — which makes it hard to provide or fund services — it’s clear they are supporting a portion of the region’s economy, and that their numbers are growing. Public records show the number of Latino students enrolled in Gallatin County schools has increased about 1% annually for the past five years, with 13.9% of the students currently enrolled self-identified as Latino. 2019 census estimates put the county’s Latino population at 4% overall.
The promotora program in Gallatin County is not the first effort to meet Latinos in Montana on their own turf. The Billings-based Montana Migrant and Seasonal Farm Workers Council, a nonprofit founded in 1972, provides health care to agricultural workers and their families on a sliding payment scale.
With community health clinics in Billings, Dillon, Lolo, Fairview and Powell, Wyoming, plus bilingual outreach workers around Montana, northern Wyoming and western North Dakota, the organization aims to serve about 6,000 people a year, roughly half of whom speak Spanish. Latino ag workers are among the most marginalized Latinos in the region.
“Many of them live in rural, isolated areas, oftentimes without a vehicle, and with language and cultural differences,” said Claudia Stephens, a spokesperson for the council. “They’re not free to just jump in the car and make a medical appointment.”
In the more rural areas, the council deploys mobile medical and dental units to give patients access to care they otherwise wouldn’t have, sending outreach workers to surrounding farms, ranches and orchards to tell ag workers about their services and get them signed up. Like the promotoras, the council’s outreach workers act as liaisons between clinicians and patients.
“We see ourselves as a door into the community,” Stephens said. “Where standard health care providers see people who come through the door, we look for those people that are not coming to the door to find out why.”
Chiara Rossi, a medical assistant and interpreter at the CHP clinic in Belgrade, has been a promotora since 2019, a few years after she moved to Montana from Italy, where she trained as a physical therapist.
Because Belgrade and Bozeman have more resources than West Yellowstone, Rossi’s promotora work looks different from that of the three West Yellowstone promotoras. But she, too, has acted as an interpreter during community events, helped eligible people apply for programs like Medicaid or WIC (the state’s supplemental nutrition program for women, infants and children) and helped people sign up for cancer screenings.
At work, Rossi notes which patients might need more help from a promotora, and then she typically spends at least one of her days off each week helping them make appointments and doing whatever else needs to be done.
“It’s challenging, because you have to figure out stuff that you’ve never had to,” Rossi said. “And if you are figuring out stuff, yourself, on a daily basis, can you imagine how confusing it can be for patients — especially if they’re not proficient in English, if they don’t have connections in the area, if they can’t put gas in their car to go to a medical visit or the pharmacy to get medications, or [if] they can’t even read in Spanish?”
“We need our patients to know that if there is a need, they can contact us,” Rossi said. “Sometimes people feel doomed because they don’t know there is a solution. So that’s why we’re there.”
Nascimento, the Brazilian-born promotora, recently helped a friend and her husband with rent assistance paperwork. Both had COVID-19 and had to stay home from work with their four children to quarantine.
“We work with community that we consider family,” Nascimento said. “I basically don’t consider that work. … I would [do it] if I was a promotora or not. The good thing about being a promotora is that I have the resources and the information to do that now.”
