Listen: Integrating What’s Real in the Community

Vision y Compromiso Executive Director Maria Lemus promotes community well-being through the training and support of promotores and community health workers.

She shares engaging stories of how she came to understand inequity personally, what equity and cultural humility look like, and new approaches for partnering with communities. As Lemus describes it, “health equity is taking what’s real in the community and integrating it into a system that doesn’t know about it.” You’ll get new tools and a big dose of inspiration from Lemus.

CCI: Maria Lemus has been the founding executive director of Vision y Compromiso since 2000. The organization provides leadership capacity, building and advocacy for over 5,000 promatores and community health workers associated with clinics, hospitals, and community-based organizations to achieve healthy and dignified lives for the Spanish speaking Latino community. Thank you for joining us, Maria.

MARIA LEMUS: Thank you very much.

CCI: I’m Suzanne Samuel. I am with Center for Care Innovations. So, we are here today to talk about how we achieve health equity as we care for patients against the backdrop of COVID-19 and systemic racism.

MARIA LEMUS: We look at health equity in terms of equal access to everything and not only access, but availability and the opportunity for us to, to grow and to benefit from what the society has to offer. We come here as an immigrant community, as my parents did, hoping for the best for their children. And the best opportunities, the best in education, the best in health. And the system doesn’t afford us, the American system. Much of it is historical with structural racism, and I mean, it’s a long discussion in itself. But we come here really wanting the best future for our families. And systems, one, we don’t understand them. And secondly, they’re not really conducive to a new generation of peoples that are coming here. And what I hope is that those systems can break down and they can really conform to the new communities that are coming to the United States and really afford us the ability to participate in everything that the United States has to offer.

CCI: How do you know when you have health equity and how do you know when you don’t?

MARIA LEMUS: That is such a great question because I remember growing up. And I grew up in segregated America, when Mexicans were on one side of the city, Blacks were on the other side, and whites were on the other side. And I didn’t see a white person till I was in high school. I grew up on the other side of the tracks, and I worked in the fields along with my parents and my uncles and my cousins. And lived a very structured life, but it was a wonderful life. We had food. Sure, we were farm workers and my mom cleaned houses and my dad worked in the fields, but for azll intents and purposes, I grew up in a very loving environment, a very supportive environment.

And it wasn’t until I got to high school, I remember the young doctors’ sons. There was one young man in the 10th grade, when he turned 15, his dad gave him a brand-new Mustang car. I remember that it was a doctor’s son and then there were others. And it wasn’t until I was in that environment that I understood the disparity, that I understood the difference in the lifestyles across the city and then where I lived. I still didn’t feel disadvantaged, and I didn’t feel the inequities until I wanted to go to college, and I couldn’t go until I wanted to take certain classes and I couldn’t, until I wanted to further myself and the system didn’t allow me to. But before that, I felt perfectly fine in my wonderful cocoon of an environment with all my Mexicano family and friends. But the system told me I was poor, told me I was disadvantaged, and told me I was quote, not worthy. But before the system put all that on me, I pretty much felt okay.

I think we look at over generations … What are we accustomed to? And what’s our expectation? Especially when a system keeps telling us that you’re undereducated, you’re poor, you’re sick. They keep putting that on us. And so, in some ways it is without even our knowledge that we become who they tell us we are. And that is, I think part of what we have to break. With Vision y Compromiso, we started really looking, coming together as mostly women who understood the importance of mutual support, who understood that we were the experts in our community, who understood that we were constantly bringing resources to the community and bettering our lives. And over 20 years that’s what we still continue to do. We honor those men and women who are in the community. They may not have a high school degree or college degree, but they are the ones who are important. They’re the ones who continue that daily struggle of bringing and taking information to an from our communities. So, we honor what we now recognize as resiliency factors. We didn’t know that term 20 years ago. We did not know “social determinants” 20 years ago. What we did know was we have a resourceful community. We know how to get information. Our indigenous historical ways are still important, and we need to honor those.

And we have a structure that is supportive. We also knew that we could leave our community, we could mingle with others, and we could bring that information back. And so we continue to build on that over 20 years. And now what you have is the expertise of community leaders of promatores, community health workers, leaders, and we honor that. And so we’ve been able to build on what is very common to us. I think what we may have a difficulty with is that multi-generational piece is over time, we changed so much. And so the Latino of 20 years ago, in three generations, my children, I don’t have grandchildren, but my children and then the grandchildren, if they don’t keep a close tie to the historical importance of the grandmother or the aunt or the uncle, or the promatores, a lot of those resiliency factors get lost.

For instance, why do we celebrate the Cinco de Mayo? It’s not a Mexican holiday. It’s an American holiday. And it is really a holiday that is mostly a for-profit holiday. The day that should be celebrated isn’t September. So how do you bring that forward over three or four generations to understand the historical importance of Latinos, of Mexicanos. That this was our land. If those things aren’t taught… I have a minor in Chicano studies, and just like the African American history and the Mexican history, the Latino history, if you don’t bring that into the discussion, then over time, our generations don’t understand the pride of who they are, don’t honor that the customs and the traditions. And the food, for instance. We talk about obesity in our communities, we talk about chronic disease in our communities. But I grew up with nopales. I grew up with frijoles. I grew up with arroz and with sopa — very healthy foods. I grew up with tortillas, but they were corn or flour. Our indigenous cultures are very healthy. It’s that generational misunderstanding of trying to be American.

And so I remember graduating from high school going to junior college before I got into university. And I say to promatores, for the sake of being American, you know, the melting pot, my era was the melting pot, where you had to become this quote American. For the sake of being American, I lost and left behind many of my traditions that were very honorable and healthy traditions. And I think that’s part of what happens in our society.

And so how do we get back to that? And I was so happy and so blessed the 22 years ago, at another conference that I put together for HIV and Latinos, I reconnected with promotores. And I walked into this room of 400 promatores from across the Southwest. And I was so happy. I reconnected with my mother and my grandmother and my aunts and my uncles who had since passed. And I was in a room full of people I understood, who understood me and I recognized. And so we have to continue reconnecting with who we are, and I’m blessed. I’m so blessed to be part of Vision y Compromiso because that’s who we are. We’re always going to have immigrants in the United States, what a blessing that we will, from whatever country we will. And so we’ll always be able to reconnect with that grandmother or that aunt or that uncle who have since passed because the culture is still there. If I want to reconnect with the food, I go to somebody who’s still cooking that food, for instance.

CCI: Tell me how that reconnection, which is so important, ties into health equity.

MARIA LEMUS: Well in health, the systems that have been developed to help us be healthier on not necessarily systems that we understand. So I’ll give you an idea, an example. When we developed our core curricula, which is comunidades transformando, transforming communities, it was about 15 years ago. It was developed because we had a National Heart and Lung Institute grant where we were to work on hypertension and heart. And so we developed a curricula to train promatores on self-empowerment, but also eating healthier. And the pilot was at a clinic called Clinica Ole in Napa. And it was developed by the farmers for farmworkers. So the class, the curricula, was given to about 20 patients who were all farmworkers who had diabetes. We met every Wednesday for gosh, forever. Like six months. After they got up out of the fields, they would come and they would meet with us and we would do this training. So the nurses said, well, we’ll give you… you know, they gave us some snacks. And the snacks were raw vegetables, broccoli, carrots, cauliflower with a dip. And the first time they did that, nobody touched it. And the nurses said, “Well, what’s up? Why aren’t they eating this?” And so I knew, but I went back to the group and I said, “what do you think that?” They said, “Well, we don’t really eat broccoli, nor do we eat cauliflower.” I said, “Okay, so let’s talk about this. What do you suggest?” I said, well, they’ll rotate and they’ll bring food. So the next week they brought a nopal salad, cold nopal salad. The next week they brought chayote. And they brought their healthy indigenous foods. So health equity is taking what’s real in the community and integrating it into a system that doesn’t know about it. And what should happen is then, as we’re talking about diabetes or about any chronic disease, it’s really not so much looking at it from a public health perspective, but how does it relate to the community that you’re trying to serve. Instead of imposing it is integrating. I think that’s a big difference. It’s not just for Latino community. It’s for all racial and ethnic communities. How do you integrate, in a healthy, way what’s common and well understood for healthier community?

CCI: I love that definition, Maria. That health equity is taking what’s real and integrating, not imposing it, into communities. Many of our listeners and many members of the CCI community are focused on small-scale changes around health equity, changes that they can test, implement, pilot. But some struggle with where to start. If you were just starting on this journey to try to achieve greater health equity, where would you begin?

MARIA LEMUS: Well, I would begin where we began 20 years ago, which is really with a community and not the community leaders. Because a leader is either someone who was truly assigned by the community or self-assigned. And sometimes self-assigned community leaders are not really community leaders. And we started by just bringing people together. And then when we had enough of a group, it was constantly asking, “What do you think? What works for you?” in a very respectful and humble way.

One of the leaders who was one of our mentors in the beginning was Rosa Martha Zarate Macias, who was a founder of a group in San Bernardino. And I went to her and asked her and said, “Would you like to be part of this?” And then she said, “Meet with this group.” So I had to start meeting with community. And what was most important in building those early relationships I learned was humility. That you go into a meeting asking and listening and then moving forward on what they suggest. I still remember this one meeting I had with them. And all these people came to this meeting and I thought they were only giving be like five. So I got up early in the morning and I bought some drinks and some fun because in the Latino community, you’re always taking food with you. And it wasn’t enough for the group. And so I was kind of wondering what would happen. And this wasn’t something I thought I should do, it was just tradition. My mother always said you do these things. So they came and each of them took a little bit of the drink, champurrado. They knew there wasn’t enough, but they each took a little bit it, everybody got a little bit of it. And I was really embarrassed and kind of beyond myself at that moment. And they came up to me and they said what wasn’t important was the amount. What was important was that you brought something. It was that you thought about us. And so my tradition said, you will bring something to a gathering, or as you leave, you will always give something. Not knowing that that was the humility part of what was important to them. That I didn’t just come with a pencil and a paper and hand to say, tell me all your wisdom and I’ll go forward. It was instead, I come here asking you and with the humility of asking you. And it’s a very important distinction I found because our success with Vision has been, I never really impose anything on anybody. It is a discussion and staff does that. I mean, we’ve grown tremendously and the network, but it’s always asking, “What do you want? What do you think? And how should we do it?” And then honoring that through the process, not translating it any in any public health language, not turning it into any logic model. While we do, do logic models, but not really transforming it, but really honoring the essence of what it is that they’re saying and the way that they’re saying it and the way that’s impactful to them. That then builds a relationship, it builds leadership, and it builds this bridge where they trust you. And I think that’s really important.

CCI: I’m hearing great examples of the importance of building trust, approaching with humility, approaching to listen and ask. f someone listening is working with a community who is not their own and they don’t know their traditions, what would you advise? What’s a good way for them to come with the right approach when they may not know the right approach?

MARIA LEMUS: I don’t think they have to know the right approach it. I think it is that humility piece. I think there’s a lot of known that there are non-Latinos who are cautious about entering our world. And at some point, it really doesn’t have to do with color. At some point it has to do with that humility piece. For instances, Suzanne you’re willing to come into our environment and people can feel it. It is a touchy feely. thing People can feel this, or, I mean, it’s almost mystical. People can feel an aura around you if you’re willing to be open to listening and to being part of it. I know that people come into our groups of promatores and they’ll say we just had a training and it was great. I say, “Well, how do you know it was great?” They say, “Well, you know, we did the training and we asked questions, and nobody had any questions of us. It was great.” I go, “Well, if you reflect on that, what that means is they didn’t understand it. They didn’t really care, and politely they’re not going to come confront you because that’s our culture.” So it’s understanding the nuances of who you’re speaking to and being open enough to have a conversation with people. I think a lot is the posture. A lot is the way that you are in that environment. Who I am with you, Suzanne, and who I am with a meeting at the department of health is different than who I am in the community. Because the posture is different. The authority is different. While there is authority in the department of health, for instance, or policymakers, you enter that arena with a different posture, as you would if you’re in a community meeting. it should be a different posture. So I would just encourage people to think about the intent, the process, and how you come off in that environment, as opposed to the one that you’re typically in.

CCI: How are you seeing organizations address health inequities today that is different from even a year or two ago?

MARIA LEMUS: Well, I love our current state administration. I love the idea of Governor Newsom. I love the intellectual intent, for instance, of our government. I was in state service during Governor Brown’s first, his first governorship. And it reminds me of that, where the intellectual ideas are so great and moving forward so much, moving our world so much, that it was so much good will.  I remember that. And I think that’s what we have today, but from the governor’s office to my sister in San Bernardino, it’s worlds away. And implementing something as large as the broad statements that we make, that the governor makes, or anybody makes in any department is so difficult. Because having worked for the state, there’s so much infrastructure that you have to get through. If it’s a state government, I worked for San Francisco City and County AIDS office. And the county has this infrastructure that is like moving icebergs. You just don’t move them. And so while we may have the best attention moving them to where it affects my sister, my brother, my aunt, my uncle. It affects a farmer. It effects a worker. It’s huge. I do think leadership is important, but I think we have to have more leadership. We have to have more understanding systems so that it really gets to the people that we have in mind. I think it’s not intellectualizing. The process we get caught up with DrPHs and PhDs and MPHs. This is the way we intellectualize something that’s good. And by the time it gets to community, they have to fill out a hundred forms or they have to go through all these requirements, and they just give up. Or doesn’t really reach us. And so intellectualizing health care and health equity in some ways is a barrier in itself.

CCI: Let’s say we’re talking about healthcare providers within a clinic, a public hospital. What do you think that’s different and what do you wish you saw that isn’t there yet?

MARIA LEMUS: For instance, I was part of one of the groups of the Kelling discussion. And a lot of that discussion was about systems. But what I think the discussion should be is about how to we reach people and how do we help people? I understand that the clinics are overburdened, but we have been saying lately, and I’ve been saying lately, that in order to go to scale, you have to partner with community. Why not embrace community? When I first heard about whole person care, I thought, “Wow, this is where community can really be a part of that.” Instead it’s kept within the institution. Why not partner with community? Why not support the building up a community to really take on some of these tasks, to be really a leverage in providing support? So that moms and dads don’t have to take a day off to go have an appointment. So that there are some things that can happen in the community.

Let’s take me for instance, if I had diabetes, which had done thank goodness. But if I did and I needed to exercise and to eat healthier, well, there really isn’t a system that I can take a minute off if I don’t have a car and go do it. To go to my provider, I still have to drive there and if I’m going to participate in what they have to offer. But we develop this nutrition and exercise program that I can go right around the block and exercise at an hour that’s convenient for me. Or I can go to a class and they can talk about how to cook my food in a healthier way. So maybe I won’t have chicharrones, but I can still have the food that I like and it’s healthier so that I’m not using manteca, but maybe I’m using olive oil or something. And so those are things that community has already created, not just Vision, but a lot of community agencies have developed systems of care that are already supportive of institutional psych clinics and hospitals, but there’s no partnership. And so let’s build up community, let’s build up their capacity to really be a partner. And let’s support that when you’re reaching more people and you’re reaching them in a way that’s relevant to them and you’re reaching them in a way that they understand. Hopefully that also brings jobs to the community.

We believe that we’re really involved in workforce development right now, bringing the promatore piece to institution. We do believe that a job makes a huge difference in a family’s trajectory. If you can hire a promatora in the community, either by a CBO or with an agency, that just changes that family’s trajectory tremendously because now they have income. They can buy food, transportation, housing, all those things. So we do support partnering with community. We are helping community organizations build up or training promatores. We have a workforce model that is really integrating, working with agencies to integrate the model, hopefully to partner with organizations so that there’s more of an equal distribution of support and funds down the road. So the community has some income coming in for the CBOs and for the promatores. But more than that, there’s a partnership, not a poor you community, but really well community. You have all these resources. Let’s partner.

CCI: Thanks. And I’m glad you brought us to talking more about promatores and community health workers. Since your organization supports more than 5,000 of them. First, explain the difference, please, between promatores and community health workers.

MARIA LEMUS: Well, 20 years ago, when we started, everybody was a promatore. Well, let me not say everybody. I worked with the AIDS office and during the epidemic, there were CHOWs — community health outreach workers. And so that’s where I first met CHOWs, or the community health worker model, was in the AIDS office when they integrated that as an outreach strategy. And it was mostly developed during that time. Although there were community health workers also with the war on poverty before that. And there, there are CHRs in the American Indian community. So there are, there were already some institutionalized positions like that.

When we started, with the promoter model, most everybody, most promatores 20 years ago were volunteers. That was the model. They were affiliated with organizations or there were volunteers in their communities. Like my mother, she was a promotora, she would help in the community. She wasn’t necessarily affiliated with anyone, but it is what we call the spirito servicio. It is something that is in us, that we help in our community. And every community has a promatore. They may not call them that, but we all have an uncle or an aunt or a mother or grandmother who was that person. And so we started to come together, and they’re great leaders. They’re very active men and women, mostly women. And they started to want to learn more. They wanted to form these relationships with others who are doing similar things. They wanted to really push this in the community. Here we are experts, how can we help you. So the committees grew from five to 13 to other states, always bringing these leaders together.

And then around 2003 or 2004 or something, we started going to a paycheck, talking about this leadership and community health workers. And we started being part of that discussion. And really, and I think that’s where not because of us, but that’s when I think the whole idea of integrating the model through chronic disease first started being integrated through diabetes. And then the national diabetes prevention program was very popular, integrating promatores, and really looking at us as that bridge and that resource. It just expanded.

And then with whole person care, it became a little more popular, that it became more institutionalized in the community. And that’s where to community health workers started to really develop. And we have slides, presentations that we were doing many years ago, and there was a clear distinction between the two. One end was promatore, and one end was community health worker. Our language even said, community health worker was an institutionalized position, promatore was community.

Now over time, there’s a lot of gray in between because you can have the characteristics of a promatore in a community health worker position. For instance, the Transitions Clinics out of San Francisco, they are clearly promatore centered. They require them to be from the community. They do a lot of training. And many institutions do that. But there are other institutions that have taken the promatore slash community health worker model and replicated it in their own vision, so they develop it as their needs are within that institution. And we’ve also know that the titles are different based on the funding. So categorical funding will oftentimes prescribe the duties and the responsibilities based on that project. There’s a lot of variables over time that have occurred that will define whether it’s community centered or a little more institutional centered.

What we say is that all positions are great and necessary, but they should be defined by the work. And if, for instance, a community health worker is doing data entry and is more in the institution that maybe it shouldn’t be called a promatore. Maybe that’s a different responsibility. We enter into this discussion at the national level, as well as the state and the local levels, really helping to inform agencies about the model and the variations and that they have a choice to develop this. But what we encourage them is to develop a model that’s relevant to the work and to the community, so that they don’t get frustrated because they thought it was going to do something, but it didn’t do it because it didn’t define it properly. We do a lot of technical assistance right now with agencies on first discussing, “What are your needs? How can we help you? How can we help you develop the right model for the right program for the right community?”

CCI: If one of the other organizations listening wanted to use community health workers or promatores in a more robust way, or maybe start using them at all, what would you suggest?

MARIA LEMUS: We’d love to chat with them. We do say it’s the integration of the model. It is more than an economic discussion about the model. It is more than even a public health discussion. It’s really a community discussion because when you integrate the promatore model, you are bringing in the face of the community. So that person should reflect, and you want to integrate them not only within the project, but within your system. We want to make sure that there is a warm embrace to that model, to that person that comes in, because they’re going to be reflecting the work. And if they’re not happy in the institution, they kind of show it directly or indirectly. And we want all these programs to be successful. It is really integrating it in, in a thoughtful way, in a relevant way, so that you bring in these wonderful men and women who are doing great work for the project, but also are spreading the word. And that’s the partnering piece. Because if you get the right person for the right job, then they’re going to go out in the community and they’re going to be the face of the organization. They’re going to get more people to come to abide by whatever project that they’re talking about. And you’re going to see more success. But if you, if you don’t and if you get the wrong person, then that also has a negative.

CCI: What advice do you wish you had received when you embarked on the journey toward health equity?

MARIA LEMUS: Rosa Martha, this woman I met mentioned as my mentor, asked me early on … remember, I started as a volunteer. We organized in my dining room with my kids around. And she came and she said, “What price are you willing to pay?” And I thought she meant monetary, you know, what price in goods. What she really meant was what price was I willing to pay in terms of changing my whole way of thinking around. In terms of doing something that was uncomfortable to me at that time. In terms of stepping outside of my comfort zone. And I didn’t understand that then, and later, I mean, now I understand clearly, but it is what price are you willing to pay to see success? So my husband will say to me, “What price are you willing to pay to see Vision y Compromiso succeed?” Which I would say to, to all the other people, “What price are you as a leader, as an administrator, as an a director, as a CEO, are you willing to pay, to see more health equity? Are you willing to change your frame of mind? Are you willing to consider other options? Are you willing to accept you’ve been wrong? Are you willing to look at someone else being a leader in this space? Are you willing to be humbled by other expert, by community experts? What are you willing to do to see success?” And I think for me, that was a big, big step. I had to move out of my comfort zone, as being the former bureaucrat with the department of health services and at the county level to say, “I thought I knew at all.” To step out of that and to move into the space of community that says, “Well, tell me what you know, and how we can work together.” That’s a big one. I think if we can do that, I would encourage us to think about that because it means giving up some of our own, giving up some who we are for the better good.