This story was written in partnership with the Southern New Mexico Journalism Collaborative.
At the height of the COVID-19 pandemic, Loretta Gonzalez would stand outside a southern New Mexico community center awaiting senior citizens who were arriving for their daily drive-through meal distribution.
With pen and notepad in hand, she’d peer into cars and trucks, smiling back at the masked faces of the elderly who could no longer gather and socialize in the center.
“I would ask them if there was anything they wanted to say to the group,” said Gonzalez, a community health worker in Radium Springs, a small community of about 1,500 along southern New Mexico’s Rio Grande.
She’d jot down their responses and, during spare moments of the day, translate them into English and Spanish, typing them in large letters onto a single sheet of paper. Then she’d make photocopies and, in the next drive-through meal distribution, would await the return of the elderly circle of friends, now with a stack of their messages to each other.
“I would hand it back so they could see what the others were doing. It was kind of like ‘Oh, look, Maria Elena is doing alright’ or ‘Oh so-and-so had a brand new great-grandchild.’ You know, things like this,” Gonzalez said. “A lot of seniors don’t have the capability to text or to do technical stuff. So I figured this was a good way to keep in touch.”
It was one of many ways that Gonzalez and other community health workers helped to buffer the damaging effects of the pandemic on the vulnerable population in the isolated regions of southern New Mexico. Gonzalez is one of about 730 community health workers statewide — or “promotoras,” as they are known in these rural Hispanic neighborhoods. They are part of a network of support that include more than 160 community centers and community health centers intended for community gatherings and care that have been put to new purposes — ones which could extend well beyond the pandemic.
New Mexico’s southern 13 counties have had a higher pandemic death rate than the northern counties. According to an SNMJC analysis, the southern part of the state had 515 COVID deaths for every 100,000 residents, compared with 461 COVID deaths in the northern half of the state. Nationally, the hardest hit during the pandemic were the disadvantaged communities — the poor and uninsured — and for New Mexico, with the third worst poverty rate in the United States, COVID-19 made no exceptions.
Bilingual organizers with deep inroads and kinship in the rural New Mexico neighborhoods, promotoras have been “a vital connection in the community” that the government has utilized to distribute information and provide medical and mental health services during the pandemic, said Claudia Mares, community outreach coordinator for the Doña Ana County Health and Human Services Department.
“We partner with a lot of agencies so people are familiar with our community centers,” she said, adding that promotoras in Doña Ana County typically have “between 50 to 60 thousand encounters” with the community each year. Doña Ana County has about 15 community centers and about 20 promotoras on staff at seven of these centers around the county.
As of September 2022, New Mexico Human Services had a little more than a million — 1,070,231 — encounters around the state, according to agency data. Doña Ana County promotoras came in second in the entire state — 139,338 — behind only the vastly larger metro area of Bernalillo County, which had 300,579.
Pandemic highlights challenges of rural care
In states with large rural communities like New Mexico, where 60 percent of its residents live in rural areas, the first waves of the pandemic brought challenges in reaching rural communities where spotty or nonexistant internet service, undocumented citizenship status and language barriers interfered with the flow of critical information.
Jodi McGinnis-Porter, New Mexico Department of Health spokeswoman, agreed that promotoras have been a critical resource for the government during the pandemic, assisting with everything from primary care, dental services, school-based and behavioral health help, she said.
The promotoras at the community centers “were very important during the pandemic because that’s where community members relied on obtaining information on various topics,” she said in an email. Critical matters like “vaccine registration, COVID testing, housing assistance, food pantries” were set up “in rural and frontier lands within New Mexico.”
The New Mexico Human Services Department, which is also responsible for a broad array of health programs for disadvantaged New Mexicans, reached out with promotoras throughout southern New Mexico to help “community members with completing applications, gathering information and submitting them” said Marina I. Piña, director of communications for the New Mexico Human Services Department.
“When the pandemic started, and as it progressed, we kept open and continued serving the community,” said Piña. “Oftentimes in the parking lots of our offices around the state.”
Gonzalez said an effort to provide testing to rural southern New Mexico was particularly successful. Multiple teams of promotoras from the region’s community centers came together to give out COVID tests in Salem, a small community between Hatch and Caballo Lake.
“In Salem alone we gave out 12 boxes of test kits. And that was in two hours, more than a thousand kits,” she said.
A study by the University of New Mexico conducted during a 2020 COVID-19 spike revealed the value of these promotoras in improving the quality of health service for “difficult-to-reach, marginalized populations in Bernalillo County and elsewhere in New Mexico.”
In this UNM “Community Health Worker Model” study, New Mexicans visiting community health clinics were screened to identify those with social needs — poverty, language or other indicators of marginalization — and were then referred to an in-house promotora for additional culturally relevant guidance.
When promotoras were used, the study found, the number of unexpected emergency room visits dropped by 12 percent. This potentially saved New Mexico healthcare payers almost $2,500 “per consumer per year” for those enrolled in Medicare Advantage or Managed Medicaid, the study found.
Those numbers are significant, considering that the Medicare and Medicaid currently cover more than half of the state, about 1.3 million New Mexicans, with New Mexico’s Medicaid being “easily the largest payer in the state” for health care services, according to State Medicaid Director Nicole Comeaux.
Vaccines, an example of promotora success
Other research shows that promotoras were crucial in identifying the negative attitudes that were undercutting vaccination rates of minority populations during the pandemic. A study to be released in December by SSM Qualitative Research in Health, a peer-reviewed journal on global health research, indicates that many immigrants in Los Angeles County, the demographics of which mirror New Mexico, mistakenly believed that COVID-19 vaccinations were a government attempt to monitor them.
Mercedes, a 38-year-old promotora who did regular outreach to immigrants, told the authors of the study that many immigrants believed that the government wanted “to dominate” immigrants by tracking them with vaccines.
The CDC has stated that vaccine data may not be used for any immigration enforcement, but many immigrants were still wary of getting their vaccination.
“Growing anti-immigrant sentiment, even amid a global pandemic, have led minorities to perceive the social and political system as rigged — deliberately targeting them and COVID-19 vaccinations,” the report stated.
In New Mexico, the proportion of immigrants in the southern half of the state is nearly twice as high as those in northern New Mexico — 12.7 percent versus 7.8 percent, respectively, according to a county-by-county analysis of U.S. Census data conducted by the Southern New Mexico Journalism Collaborative.
Ramona Urbina, a promotora for the nonprofit Empowerment Congress, remembers the time early in the pandemic when they would go door-to-door checking on residents in the state’s poorest neighborhoods.
“The people we would visit were scared, and we were scared,” Urbina said. “We had on all of our protective equipment masks and face shields, it was a scary time. But it was important for us to let people know where help was available. Almost all of the people we visited wanted to get the vaccine.”
Claudia Mares, community outreach coordinator for the Doña Ana County Health and Human Services Department, said that promotoras were on the front lines of battling the pandemic even when other community sectors shut down.
“Regardless of the community centers being closed, the community healthcare workers, the promotoras, they stayed active,” Mares said. “We used the drive-thru distribution as one of our main outlets,” she said, and they all mobilized to filter into the neighborhoods of rural county areas for a variety of the government’s COVID emergency initiatives.
“Different agencies needed different types of surveys and different types of outreach. So we had to go old-fashioned, printed stuff,” Mares said. “Most of our communities don’t necessarily rely on access to the internet because sometimes there is no internet. So we printed a lot of our material and handed it out,” she said.
The future — and challenge — of promotoras
The collective knowledge of promotoras, and the trust that they have built in rural New Mexico, runs the risk of being underutilized, Mares said, if public policy planners fail to tap into their experiences.
“When the CEOs, the presidents, the managers, when they are coming together, if there is not a member of the community who is bringing that community perspective … then all of these officials can forget that there is a human component in there,” she said.
“At the planning level, unless we bring somebody from the community who brings that perspective, then there is always something missing,” she said. Otherwise, “the human component is not there.”
Findings from the SSM Qualitative Research in Health study confirm her belief, particularly in the deadly wake of a pandemic.
“Promotoras’ perspectives are integral to the development of strategies and approaches to address COVID-19 vaccine hesitancy, uptake, and implementation among underserved communities,” the article stated. ”They are trusted pillars in their communities, uniquely poised to promote COVID-19 vaccine uptake in the area they serve. The knowledge and skills they possess are effective in encouraging fellow community members to embrace or adopt positive health-related practices.”
Promotora organizers and studies into community health workers have indicated that the array of different agencies and jurisdictions — state, county, nonprofit and, occasionally, private — involved with promotora activities has led to confusing instruction being given to communities.
A 2020 study in the Society for Public Health Education asked five experienced promotoras for the biggest obstacles for success, and they identified a variety of issues: discriminatory and misogynistic attitudes from both community members and health providers, the emotional burden of hearing about people’s problems, limited English skills of promotoras, and logistical problems like transportation and promotoras’ limited skills at data collection.
The NMDOH has addressed some of these problems by starting the state’s Office of Community Health Workers — one of the few in the nation — and has “developed a standardized, statewide training program and a certification process for community health workers,” according to a statement from NMDOH.
The Commonwealth Fund published a study after the start of the pandemic that highlighted a pivotal problem with the promotora model: proving the value of promotora programs.
“Convincing state and local agencies outside of the health sector to support CHW services may require more explicit evidence of the return on investment,” stated the case study.
New Mexico has made strides in those investments — and in highlighting the value of promotoras’ expertise. For example, the University of New Mexico Family Medicine Residency placed family medicine residents into a New Mexico community clinic that serves low-income Hispanics and is managed by promotoras.
“Residents gained skills from (community health workers) in inter-professional teamwork, cultural proficiency in patient care, effective communication, provision of cost-conscious care, and advocating for both individual and community health,” a study of the experiment found.
The project, the study stated, was “a powerful rationale for greater recognition” of promotoras’ expertise.”
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Reyes Mata III is a reporter for the Southern New Mexico Journalism Collaborative.
