The Invisible Health Care System

The great majority of human ills are never seen by a doctor. The real primary care is provided by one’s family, close friends, and neighbors.”

Dr. Eva Salber, professor emeritus at the Duke University School of Medicine, is a gentle, self-possessed woman in her early 70’s. Her intelligent brown eyes glow with feeling as she describes the unsung “lay health facilitators” who, as her work has shown, provide most of the health care in virtually all communities. She believes that these lay health facilitators are the pillars of an invisible health system that provides the greater part of health care in every community. Salber’s lifework has been to get these “natural helpers” the recognition and support they deserve.

Salber’s original groundbreaking lay health facilitator project took place in 1977 on the outskirts of Durham, North Carolina. Salber and her coworkers began by asking area residents: “Who do you know around here who gives good advice on health matters—other than doctors?” They found that the same names were mentioned again and again. Salber and her colleagues then visited each of the 39 individuals who had been mentioned most frequently and told them they had been identified as a person trusted by the community, someone people came to when they needed help and advice. They invited the natural helpers to meet in small groups and tell them what additional information might be useful in their efforts to advise their friends and neighbors.

The topics the natural helpers wanted to know about ranged from self-diagnosis, use of over-the-counter drugs, and doctor-patient relationships to high blood pressure, anemia, and cancer. They met in groups to discuss their most pressing concerns. When appropriate, Salber arranged for experts to answer specific questions.

As part of the project, the natural helpers kept track of the questions they were asked. The researchers concluded that the 39 facilitators dealt with about 6,000 requests for help per year. Some queries were for problems as minor as colds. Others were as major as alcoholism, cancer, and attempted suicide.

“The range of problems, people bring to friends and neighbors is much broader than those brought to doctors,” Salber explains. “Less than five percent of physicians’ visits are for psychological problems. That’s because we learn that if we want a doctor’s attention, we must focus on a physical symptom. A woman might tell her doctor she has a bladder infection. But she might tell her health facilitator that she’d lost her job, had a fight with her husband, and has a bladder infection.”

Salber believes that when people develop health problems, they first attempt to deal with them on their own. If this fails, they seek advice from a family members, friends, or neighbors, which is where the natural helpers fit in. They may also seek information from books, magazines, or television. It is only after they have exhausted their informal options that they consult professional health workers.

Salber feels that natural helpers could provide even more information and advice than they already do if they received a minimum of encouragement and support through programs such as hers. She also believes that professional health workers have much to learn from their lay counterparts.

“Our lay facilitators are the most highly trained specialists we have in understanding the whole person,” she insists. “Yet because they are not paid and are part of the informal community network rather than the formal medical system, they have remained almost entirely invisible—they are ignored by health professionals and researchers alike. At a time when laypeople are taking more responsibility for their health and health professionals are struggling to cut medical costs without sacrificing quality of care, these natural helpers may very well prove to be our most important untapped resource.”

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Written by Tom Ferguson MD

Explore Wellness in 2021