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BY: FR. ALOYSIUS OCHASI, MA, STL, and FR. PETER A. CLARK, SJ, PhD

BJ was a 40-year-old undocumented immigrant from the West African country of Nigeria. He had been undocumented for 15 years, and throughout this period he never saw a physician. He self-medicated with over-the-counter medicines and, for the most part, relied on the antibiotics tetracycline and Ampiclox brought to him by kinsmen who visit his home country, where it is easy to buy any type of medication without a doctor's prescription. He did any available job that did not require documentation, and he shared a one-bedroom apartment with four other people. Sometimes they took turns to sleep.

One evening, BJ complained of body weakness and dizziness and, as usual, popped tablets of Tylenol, tetracycline and Ampiclox. A few hours later, one of his roommates knew something was seriously wrong when BJ's speech began to slur. The roommate was afraid to call 911 for fear of exposing BJ's undocumented status, so instead he called a kinsman who is a cab driver. It took the cab 45 minutes to get to the apartment. When they finally got BJ to the emergency department of a Catholic hospital in the area, he had suffered a severe stroke. With no family around to care for him and no long-term facility willing to accept him because of his undocumented status, BJ remained in the hospital for about 10 weeks before he finally died. His medical care cost hundreds of thousands of dollars.

Catholic hospitals have been at the forefront of providing health care to the uninsured, underinsured and to undocumented immigrants like BJ. However, providing such services comes at a huge cost to the Catholic health care institutions that "live amidst tension between three intersecting primary values, namely, a commitment of service to the poor and vulnerable, promoting the common good for all and financial sustainability."¹

The 1986 Emergency Medical Treatment and Active Labor Act demands that all patients who come to an emergency department for care must be treated and stabilized, but this requirement does not include further treatment or long-term care. Furthermore, the Patient Protection and Affordable Care Act excludes undocumented immigrants from health care insurance coverage or benefits.

Yet, the mission of Catholic health care stipulates that the poor, uninsured and undocumented be treated with dignity and respect. After assessing the health needs of the immigrant community in West Philadelphia, Mercy Health System, part of Trinity Health/Catholic Health East, developed a community outreach model program in Philadelphia that concentrates on the health needs of a specific immigrant community and uses the "health promoter" concept that has been effective in the developing world.² By training members of the immigrant community to help others in their culture so that ailments or chronic conditions are recognized and appropriately managed, the program aims to prevent the kind of medical crisis that BJ faced.

Data show the Mercy Health Promoter Model program works, and given the new landscape in Catholic health care that calls for new health delivery models — more community-based services and fewer acute-care-based services — other Catholic hospitals dealing with similar issues can adopt this model.

HOW IT GOT STARTED
Over the past decade, Mercy hospitals in Philadelphia have seen increasing numbers of foreign-born documented and undocumented African patients. Estimates show that there are at least 50,000 undocumented African immigrants living in West Philadelphia, constituting 8 percent of the city's total immigrant population.³

When African refugees, asylum-seekers and immigrants arrive in the U.S., they often are traumatized and shocked. They usually have no jobs and no financial support, and they frequently are in poor health after moving from town to town — or refugee camp to refugee camp — during upheavals in their home country. The children may not have been in school for several years, or they may not have been to school at all.

Undocumented and therefore uninsured, these immigrants generally lack access to primary care and show up at hospital emergency departments in the advanced stage of their diseases. Mercy hospitals find such individuals frequently return over and over again, because the patients know Catholic hospitals will not turn them away.

In response to this community need, Mercy Hospital of Philadelphia administrators Sr. Megan Brown, RSM, DMin., and Mathew Mathew, MD, director of medicine, instituted the Mercy Hospital Task Force on African Immigration in conjunction with the Institute of Catholic Bioethics at Saint Joseph's University in Philadelphia. The task force was instituted as part of Mercy Hospital's effort to address providing adequate health care to the growing undocumented and uninsured African immigrant population in Philadelphia.

The task force's mission was to develop and implement a program for this population that would provide health care for those most in need and do so cost effectively. Task force members studied health promoter programs developed by Partners in Health, an international organization that delivers health care to the poor around the world, and Creighton University's Institute for Latin American Concern in the Dominican Republic. They also examined the work of the American-based Dominican Sisters in Las Cruces de Arroyo Hondo, Dominican Republic, who have successfully organized a grassroots community health effort based on community ownership and responsible stewardship.

The resulting pilot program incorporated the successful and applicable aspects of Partners in Health's community-based model of care, the Institute for Latin American Concern's effective organization, training and operation of a health promoter program and the Dominican Sisters' method of empowering the indigenous community and letting them take responsibility and ownership.

As adapted to conditions in the developed world, particularly the city of Philadelphia, the Mercy Health Promoter model set the following goals and objectives:

• Create a community-based program involving a high degree of community participation
• Provide quality health care services by partnering with other already established organizations in the area
• Reduce the costs of health care for uninsured or underinsured individuals and demonstrate cost-effectiveness for all members of the partnership (hospitals, health care providers, sponsors of the program and the members of the community)
• Improve the health of the poor and marginalized individuals of the immigrant and impoverished communities of Philadelphia using education and increased access to primary health care services in the prevention and/or management of illness

TRAINING AND IMPLEMENTATION
The health promoter pilot program is a joint venture between the Institute of Catholic Bioethics and the Mercy Health System of Philadelphia. The program began in November 2012 and focuses on preventing complex diseases and managing chronic conditions through education, screening and observation. Medical residents from Mercy hospitals teach select volunteers from immigrant communities about diseases and conditions such as hypertension, diabetes, obesity, tuberculosis, etc., that are prevalent in their communities. At the end of training, these community health promoters share their knowledge back in their neighborhoods by conducting non-invasive screenings, providing health and nutrition education in homes, churches and social gatherings, monitoring patient health and compliance with prescribed treatment and referring patients to a clinic or hospital when needed.

The health promoters work exclusively within their own individual immigrant communities. This is an important aspect because there are numerous African immigrant groups represented in the West Philadelphia area. This cultural, linguistic and religious diversity has led to some tensions between the various groups represented within the community.

The health promoters also serve as liaison between the immigrant communities and the Mercy hospitals, and they meet periodically with sponsors of the program and representatives of the hospital professional and clerical staff for debriefing. This gathering is a forum for the health promoters to provide useful information on the immigrant communities' culture, religion and concerns regarding health care access. Such cross-cultural symbiosis enhances cultural and religious sensitivity at the Mercy hospitals and, it is hoped, will both increase the stature of the health promoters and increase respectful interactions with the community in general. Ultimately, such sensitivity will encourage community trust, participation and cooperation, especially in a big city like Philadelphia with a large and growing immigrant population.

Of the estimated 50,000 African immigrants living in the Greater Philadelphia area, the largest communities are from Nigeria, Liberia, Ethiopia and Ghana.⁴ The project task force chose the Nigerian community for the pilot program because it is well organized and has a stable base at St. Cyprian Catholic Church's parish in West Philadelphia, where communities from the French-speaking West African countries of Benin, Senegal, Togo, Côte d'Ivoire, Niger and Cameroon also worship.

The Nigerians are family-oriented and deeply religious. Sunday Mass at St. Cyprian is celebrated in their local dialect, which is an attraction to those who want children born in the U.S. to have some knowledge of the family's language and culture.

To launch the program, Mercy collected a group of volunteers from the Nigerian community and prescreened them to ensure they would undertake the responsibilities of being health promoters if they were selected. About 80 percent of the volunteers had some medical background or certification such as CNA, LPN and RN, and one volunteer had studied medicine in Nigeria but had not completed a residency in the United States. Most of the volunteers were employed and married with children.

Based on information from meetings with community leaders and data from the Mercy hospitals' emergency departments, Mercy health promoters needed extensive education and training in nutrition, exercise, sanitation and compliance with medications to address the four primary medical concerns in their community: hypertension, diabetes, obesity and tuberculosis. They also needed training in clinical techniques such as checking blood pressures, blood sugar levels and heart rates. The health promoters learn to perform Directly Observed Therapy for patients who have difficulty following the regimen for their insulin or anti-tuberculosis drugs, for example, or whose language barriers keep them from fully understanding how to use the medications. The health promoters follow up on such patients via house calls and phone calls to ensure compliance. Other identified training needs included protection of patient confidentiality and cultural sensitivity skills.⁵

From May to September 2012, the health promoters went through a rigorous and comprehensive training program at the Mercy Catholic Medical Center. They set up their first screening site at St. Cyprian, a place that undocumented immigrants in the area would view as a safe haven. The intention is eventually to expand the program to other worship sites in the area.

At the church, the health promoters screened individuals from the Nigerian community and gave them educational material on maintaining blood pressure and blood glucose levels, along with health and exercise information. Patients who proved to have high blood pressure or high glucose levels, in addition to any other relevant negative health factors (body mass index, oxygen levels, weight, etc.), received an identification number on a referral card to take to the Mercy ambulatory clinic in West Philadelphia. This ID number not only protects patient privacy, it shows the clinic that a health promoter has screened, referred and created a record for the patient, and it also allows the health promoters to gauge compliance among patients who were advised to make appointments.

At the clinic, Mercy Hospital physicians, interns and residents review any documentation by the Mercy health promoters; evaluate the patient; educate the patient; and prescribe diet, medications or any other medical course of action. The Mercy health promoters follow up with the patients to ensure compliance.

Because the health promoters are well-known members of the community and trusted by both the undocumented and legal residents, they can make house calls and phone calls to remind patients to schedule an appointment with the clinic. Social services also are available to help individuals initiate enrollment in medical assistance programs. When the health promoters suspect someone has a disease, they send him or her to the emergency department, the local county health center or Mercy outpatient clinic for early treatment — a cost-effective strategy.

FUTURE DIRECTION
As of November 2012, when the Mercy Health Promoter program partnered with Mercy Philadelphia Hospital Clinic, 82 patients of Nigerian descent had been seen through St. Cyprian Catholic Church. Among the patients observed at the health promoter screenings, 49 were females and 33 were males, and a total of 40 patients were referred to Mercy Philadelphia Hospital Clinic for follow-up appointments. Data collected at these sessions revealed that a majority of patients had high readings for systolic and diastolic blood pressure, indicating an underlying condition of hypertension was common in the community.

Given the success of the program so far with the Nigerian community, sponsors of the health promoter program met in the spring of 2013 with leaders of French-speaking West African communities to discuss expanding the program.

Four members of the French-speaking communities and four others from the Nigerian community have been trained as health promoters and are now active in their respective communities. In a bid to reach as many African immigrants as possible, regular health promoter sessions have begun at another West Philadelphia church, the Redeemed Christian Church of God: Living Spring. This church was chosen because of its diverse congregation, which includes a number of members from different African nations as well as some African-Americans.

The new landscape in Catholic health care calls for new health delivery models. There is a growing need for a shift in the acute-care delivery model that has dominated Catholic health care for decades. A movement from acute-care services to community-based services, which will always have an impact on the stewardship of resources, is of paramount importance, given the trajectory of health care in the United States.

The focus is not only on the health and well-being of the individual but of the community as a whole. The idea, therefore, is to focus on the holistic treatment of people before they get sick (community-based services), while they are sick in the hospital (acute-care services), and after they are discharged from the hospital (community-based services). The Mercy health promoter program incorporates both the community-based and acute-care ideas of the new health care landscape.

The Mercy Health Promoter Model has so far proven to be an effective local response to a growing local need. Many Catholic hospitals in the United States deal on a daily basis with balancing the mission of caring for the uninsured and undocumented with financial sustainability. The Mercy model, adapted to the needs of each immigrant community around the nation, could be one solution and a paradigm for other Catholic hospitals nationally in the care for the most vulnerable members of our society — the undocumented.

FR. ALOYSIUS OCHASI is a doctoral student in bioethics at Loyola University Chicago and a priest chaplain at Holy Redeemer Health System, Meadowbrook, Pa.

FR. PETER A. CLARK, SJ, is director of the Institute of Catholic Bioethics and professor of medical ethics at Saint Joseph's University, Philadelphia.

NOTES

1. John P. Slosar, Mark F. Repenshek and Elliott Bedford, "Catholic Identity and Charity Care in the Era of Health Reform," HEC Forum 25, no. 2 (June 2013): 111-26.
2. Peter A. Clark and Luke Surry, "Mercy Health Promoters: A Paradigm for Implementing Third World Practices for Resource-Poor Conditions of the Developed World," Medical Science Monitor 13, no. 3 (March 2007): PH 1-8.
3. Robert Wood Johnson Foundation Clinical Scholars, Emergency Preparedness for African Immigrants in West Philadelphia, Sept. 23, 2009: 11. Available at: www.med.upenn.edu/rwjcsp/documents/CSPSummerProjectFinalReport2009.pdf.
4. Global Philadelphia: Meet the World Here, "African," available at: http://globalphiladelphia.org/communities/african.
5. Global Philadelphia.

ABOUT NIGERIA

Nigeria is the most populous country in Africa, with a population of about 162.5 million people in 2011.¹ Nigeria's population is very diverse, with over 250 ethnic groups. As a former British colony, the county's official language is English; however the principal languages spoken are Yoruba, Ibo and Hausa.

In 2009, about 1.5 million African immigrants resided in the United States making up 3.9 percent of the country's 38.5 million immigrants.² The U.S. Census Bureau's 2008 American Community Survey estimated a population of 206,604 Nigerian foreign-born, making Nigeria the largest African source country of immigrants to the United States.³ Poverty and the search for a better life contribute to the emigration of Nigerians to the United States and other countries. Also, millions have been internally displaced due to religious and ethnic conflicts — particularly in cities across Nigeria's Muslim north.⁴

According to the 2006 American Community Survey, Nigerians are the most educated immigrant community in the U.S. The report shows that 37 percent of the Nigerian immigrant population has bachelor's degrees, 17 percent has graduate degrees and 4 percent has post-graduate degrees.⁵

NOTES

1. The World Bank, "Nigeria," www.worldbank.org/en/country/nigeria.
2. Kristen McGabe, "African Migrants in the United States," Migration Information Source, July 2011. Available at: www.migrationinformation.org/USfocus/display.cfm?id=847.
3. Blessing U. Mberu, "Nigeria: Multiple Forms of Mobility in Africa's Demographic Giant," Migration Information Source, June 2010. Available at: www.migrationinformation.org/Profilesdisplay.cfm?ID=788.
4. Mberu.
5. CP-Africa.com, "Nigerian Diasporans Are the Most Educated Immigrants in the United States," July 31, 2012. Available at: www.cp-africa.com/2012/07/31/nigerian-diasporans-are-the-most-educated-immigrants-in-the-united-states.

QUALITIES OF A HEALTH PROMOTER

Mercy Hospitals of Philadelphia and Nigerian community leaders recommended these attributes for health promoter candidates:

• Bilingual
• Well-respected in the community
• Trustful and trusted
• Committed to staying in the community during his or her time as health promoter
• Extensive knowledge of community history, life in the community and community members
• Respectful of the ideas and traditions of the community
• A spirit of service
• Devoted to the community and not seeking individual economic interests
• Able to read, write and communicate effectively
• Responsible and unbiased
• Aware of his or her own limits and capabilities
• Dynamic
• Capable of honoring patient confidentiality
• Team-oriented