The Lives of Community Health Workers: Local Labor and Global Health in Urban Ethiopia by Kenneth Maes (review)

National experiences with community health workers (CHWs) and evidence about their effectiveness in improving the health of populations is growing rapidly throughout the world—from the prototype of the first CHW cadre using “farmer scholars” in China in the 1930s at Ding Xian,¹ to the current state of affairs where there are now more than five million CHWs providing basic and essential health care services around the world, including in the United States.² CHWs are now widely recognized as a critical resource for enabling health systems to more effectively improve the health of the populations they serve and to reduce health inequities, especially in underserved geographic areas.³ The evidence—that CHWs can save lives through promoting healthy household behaviors and good nutrition, linking families to important preventive services such as immunizations, recognizing danger signs for which treatment should be sought, providing treatment for life-threatening illnesses (such as HIV/AIDS and childhood pneumonia, the leading single cause of child death globally), and accompanying patients to health facilities for emergency care—has been rapidly accumulating during the past two decades. New evidence will certainly continue to accumulate on the effectiveness of CHWs in disease surveillance (to detect outbreaks of Ebola and other serious highly contagious diseases), in ending the HIV/AIDS epidemic and providing ongoing treatment to infected patients, in controlling tuberculosis and malaria, and in detecting and treating important emerging noncommunicable diseases such as hypertension, diabetes, and mental illness throughout the world.⁴

Kenneth Maes’s new book makes an important contribution to a void in the literature on CHWs—studies of CHWs themselves as people and of their perspectives on their work. Maes, an assistant professor of anthropology at Oregon State University, has carried out extensive field research exploring the lives and social dynamics of CHWs in Ethiopia, particularly as they relate to the broader health system as well as to the local, national, and global social/political context, including the “global health industry” (p. 7), as he repeatedly refers to it throughout his book. This book focuses on his field research in Addis Ababa during the period from 2006 to 2008 when he conducted longitudinal in-depth interviews with CHW volunteers who were working in HIV/AIDS programs funded by external donors to detect persons with HIV/AIDS, to enroll them in a program providing them with medication, and to provide social support to them once enrolled. A major theme of the book is what Maes sees as the exploitation of CHWs—by the “global health industry,” by not providing them with a living wage, and by not giving them a seat at the table in decisions about health systems strengthening.

But his book also provides a rich in-depth description of the social and political context of Ethiopia over the past half century and its efforts to address the health needs of its population through “abyotawi (revolutionary) development” (p. 51)—a hybrid approach to development that “promotes privatization and markets to some extent while maintaining relatively strong state control over the economy, social organization, and the health care system” (p. 51). And, his book provides a useful link to broader efforts around the world by social scientists to understand the perspectives of CHWs and how engaging them in defining and improving their work can lead to an even more effective CHW workforce.

This book is a call for more research on CHWs, particularly from an anthropological and social science perspective. But more importantly, it is also a call to engage CHWs in the research process and to foster coalitions that include CHWs, social scientists, public health experts, and policy makers to form a “spider’s web” (p. 147), as he refers to it (relying on an Ethiopian proverb), that can “tie up a lion” (p. 147). Here, the “lion” is global health inequity and the...