“Volunteers Are Not Paid Because They Are Priceless”: Community Health Worker Capacities and Values in an AIDS Treatment...


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“Volunteers Are Not Paid Because They Are Priceless”: Community Health Worker Capacities and Values in an AIDS Treatment Intervention in Urban Ethiopia
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Medical Anthropology Quarterly (MAQ).
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Maes, Kenneth
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Community health workers
Quality of life


This article analyzes community health workers’ (CHW) capacities for empathic service within an AIDS treatment program in Addis Ababa. I show how CHWs’ capacities to build relationships with stigmatized people, reconcile family disputes, and confront death draw on a constellation of values, desires, and emotions encouraged by CHWs’ families and religious teachings. I then examine the ways in which the capacities of CHWs were valued by the institutions that deployed them. NGO and government officials recognized that empathic care was crucial to both saving and improving the quality of people’s lives. These institutional actors also defended a policy of not financially remunerating CHWs, partly by constructing their capacities as so valuable that they become “priceless” and therefore only remunerable with immaterial satisfaction. Positive change within CHW programs requires ethnographic analysis of how CHWs exercise capacities for empathic care as well as consideration of how global health institutions value these capacities.
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! Kenneth Maes Department of Anthropology Oregon State University (E mail: Kenneth.maes@oregonstate.edu) Volunteers Are Not Paid Because They Are Priceless : Community Health Worker Capacitie s and Values in an AIDS Treatment Intervention in Urban Ethiopia ######################################################################################################## # T his article analyzes community health workers' (CHW) capacities for empathic service within an AIDS t reatment program in Addis Ababa I show how CHWs' capacities to build relationships with stigmatized people, reconcile family disputes, and confront death draw on a constellati on of values, desires and emotions encouraged by CHWs' families and religious teachings. I then examine the ways in which the capacities of CHWs were valued by the institutions that deployed them NGO and government officials recognized that empathic care was crucial to both savin g and improving the quality of people's lives These i nstitutional actors also defended a policy of not financially remunerating CHWs, partly by constructing their capacities as so valuable that they become "priceless" and therefore only remunerable with immaterial satisfaction Positive change within CHW programs requires ethnographic analysis of how CHW s exercise capacities for empathic care as well as consideration of how global health institutions value t hese capacities. [community health workers, care, value, AIDS, quality of life] ######################################################################################################### I was visiting them all that time, consoling the father, and I finally got him to agree with his daughter Now, he has given her a room in his house, and she is living properly When you reconcile others, you will give them happiness, and you will also be satisfied. When people are convulsing, gasping, and falling from bed, we correct it. We pick them up and prepare them. We wash them and we bury them. Volunteer co mmunity health workers, Addis Ababa, 2008 Volunteers are not paid not because they are worthless, but because they are priceless. A p oster at an AIDS care and support NGO Addis Ababa, 2008 Community health wo rkers (CHWs) remain a central component of global public health programs and this area of policy and practice is currently the target of much investment experimentation and evaluation For global health bodies that deploy CHWs within poor neighborhoods and districts a central challenge is ensuring their efficacy, often conceived in terms of preventing unhealthy behaviors, improving adherence to drugs and other biomedical technologies, and loweri ng morbidity and mortality rates (Lehmann and Sanders 2007 ; Singh 2011 ; Standing and Chowdhury 2008). A nthropologists and others have recently brought critical attention to this vision of CHW efficacy that prioritizes their ability to act as professional mediator s of biomedical technologies and as models and monitors of healthy behavior s ( Kalofonos 2014 ; Nading 2013) T his vision may sideline CHWs' agency in r educing poverty, enhancing social solidarity, and improving well being a key element of the ir role envisioned


! $ with in the Alma Ata Declaration of 1978 (Arvey and Fernandez 2012 ; Balcazar et al 2011 ; PŽrez and Martinez 2008 ; Sabo et al 2013 ). If the efficacy of CHWs is reduced to their successful distribution of medicines and generation of quantitative results Nading warns, CHWs' "parallel capacit y to act as advocates for a more empowering public health based on a non numerical quality of service may be obscured" (2013:99). With this warning in mind, in this article I use ethnograph y to illuminate CHWs capacities to engage in specific forms of int imate and empathic care and to reveal the ways in which the institutions deploying these CHWs value their capacities In the first part of the article I identify distinct capacities exercised by CHWs in an AIDS treatment pro gram in Addis Ababa, Ethiopia. These capacities include developing trust and intimacy with stigmatized, non kin care recipients reconciling care recipients' social conflicts and providing care recipients with "better" deaths I treat the se as especially important yet poorly understood parts of the social and emotional resilience and dignity that exist within contexts of intense poverty competition and violence ( Hussen et al. 2014 ; Klaits 2010). Thus I attempt to show how each of these capacities draws on a constellation of moral val ues, desires, abilities, and positive emotions encouraged by CHWs' families and religious teachings. The s econd part of the article elucidate s the ways in which these capacities for empathic care are valued by health institutions involved in the roll out of free antiretroviral therapies in urban Ethiopia, namely local NGOs, the government health bureaucracy, and their international donors. There are multiple ways in which global health institutions potentially value CHW capacities They can encourage th eir capacities for intimate service and make them central to a goal of providing intended beneficiaries with improved quality of life. They can also deem their capacities for empathic care and their labor in general as deserving of m aterial remuneration. The NGO Partners in Health (PIH), well known to medical anthropologists and many global public health practitioners, stands out as progressive in part because it promotes the capacities of CHWs to provide intimate and compassionate ca re, as well as a policy of providing CHWs with secure, modestly salaried employment (Farmer 2008, 2013). In Haiti and Rwanda, the organization ha s touted its efforts in poverty reduction through CHW job creation and CHW mediated successes in improving the quality of patients' lives through accompaniment, PIH's signature form of community based care that emphasizes intimate and dedicated social and material support in the face of stigmatization and poverty ( Castro and Farmer 2005) T he case that I present below of a CHW mediated antiretroviral therapy program in Addis Ababa, stands in contrast to a norm appraised in much recent medical anthropological literature of global health institutions largely ignor ing quality of life and care and focus ing on quantit ative outcomes like the number of lives saved or rates of adherence to biomedical prescriptions ( Biehl 2011; Kalofonos 201 4 ; Marsland and Prince 2012; Nading 2013 ; Prince 2012 ). T he NGOs and government health institutions involved in this AIDS treatment program highly valued CHWs' capacities for empathic care in that they devoted considerable attention to encouraging and us ing them to improve the quality of peoples' lives through the reduction of poverty and HIV related stigmatization despair and strife Yet as in many antiretroviral therapy programs throughout sub Saharan Africa, the same institutional actors promoted and defended a policy of not remunerating the CHWs for their labor (Maes and Kalofonos 2013) Interestingly, they did this partly through discourses and ceremonies that constructed CHWs' capacities for intimate care as a form of "priceless" emotional energy that is appropriate ly re munerated only with immaterial mental and spiritual satisfaction Through a set of rituals and r hetoric, the institutions thus strongly valued CHWs'


! % capacities for their impact on the lives of patients, and simultaneously avoided valuing CHWs' labor by providing them with financial remuneration that might improve their own economic and social lives In a final section, I provide evidence that t hese discourses were apparently somewhat successful in shaping CHWs' political subjectivities, motivations, and capacities. Yet CHWs also opposed the expectation that they sacrifice and exercise their capacities in return for mental satisfaction. Ethnographic inquiry is uniquely capable of illuminating the labor and lives of CHWs and their roles within public health system s By shining a light on CHWs capacities to engage in intimate and empathic care and on the multiple, sometimes contradictory ways in which health institutions value their capacities, ethnography can greatly advance understanding of the intersection of global health programs and peoples' desires for social solidarity and socioeconomic advance ment Such work can also help global health donors, policymakers, and CHWs imagine and work toward health programs that promote a broad conceptualization of care and reduce poverty by genuinely encourag ing and pay ing CHWs to engage their capacities to impr ove lives not just to monitor health and mediate biomedicine Setting: Rolling out Antiretroviral Ther apies in Addis Ababa In the late 1990s, when most HIV positive people in Ethiopia could access treatment only for opportunistic infections, NGOs began implementing forms of home based care (HBC), defined by WHO as care including physical, psychosocial, palliative, and spiritual activities delivered by local volunteers to help the ill and their families achieve their best quality of life ( WHO 2002:8). At this time, h ighly active antiretroviral therapies (HAART) were un available to people in poor countries When global health partnerships moved to make HAART more widely accessible i n Ethiopia and sub Saharan Africa more generally around 2004, they called on CHWs to continue providing HBC in addition to drug adherence support In Addis Ababa, clinical operations were carried out within the public heal th system, while HBC remained the responsibility of local NGOs, which received funding and support from international NGOs and donors but also cooperated closely with local government bodies and their policy interests Food and ho using support, small income generating plans and funeral services were also provide d through cooperatio n between NGOs, government bureaucracies and c ommunity associations Across sub Saharan Africa and in Ethiopia, most CHWs engaged in HAART support and home base d care have been expecte d to work as unpaid volunteers, due to what Swidler and Watkins (2009) call the "sustainability doctrine" the steadfast idea that health development project s are sustainable only when local organizations can take over the project and sustain it with local initiative and labor when the donors with draw their resources. In this approach to sustainability, creating jobs and paying local labor with international donor funds is considered a bad idea, because these expenditures cannot be sustained when internatio nal funding is removed by local organizations and governments that are strapped for cash and constrained by I nternational M onetary F und influenced wage caps (Pfeiffer and Chapman 2010). Within this framework, global donors, policymakers and programmers must choose between job creation and sustainability; in choosing the latter, they must then rely on and attempt to coax local peoples' willingness to donate their labor A prominent internati onal NGO involved in HIV/AIDS care and treatment support in the study setting was Family Health International (FHI). A 2006 qualitative evaluation of FHI's HBC program s in urban Ethiopia commissioned by the organization, makes clear the aim to


! & "improve the quality of life of patients and their families" while also improving access and adherence to antiretroviral drugs (Yilma 2006:4). Conforming to a process of data collection and report writing that is common among donor funded programs in "Africa's AIDS industry" (Watkins and Swidler 2012), t he evaluation cites widely shared testimonies (among volunteer CHWs, their supervisors, and care recipients) of improved health and reduced HIV related sti gmatization and abandonment amid the ongoing challenges of widespread unemployment and insecure access to food and housing The report does not, however, consider the idea that paying the CHW s might be a way to help reduce unemployment and food and housing insecurity. Instead, the report claims that the program "had been successful in instilling the spirit of voluntarism in the care givers." Methods Over the course of 22 months (June August 2006; May 2007 December 2008), I co nducted fieldwork with CHWs from two local NGOs in Addis Ababa : the Hiwot HIV/AIDS Prevention, Care, and Support Organization a relatively large NGO and local implementing partne r of FHI and the Medhen Social Center, which received funding from a mix of smaller international donors. Medhen was run by nuns of the Ethiopian Catholic Church, yet not as a f aith based organization F rom 2004 to the time of the present study, b oth the Hiwot and Medhen NGOs through their CHWs, provided home based care and treatment support for a rapidly increasing number of people accessing antiretroviral treatment at ALERT Hospital, a public hospital on the southwest outskirts of Addis Ababa. Despite their differences, these NGOs coordinated their home based care activities and shared similar operational values and protocols. The ir CHWs were expected to serve for a period of 18 24 months, and spent an ywhere from 15 to 40 plus hours a week visiting the homes of a dozen or more care recipients, providing counseling, treatment support, and care, and accompanying people as they sought resources from clinic s NGO s or local government welfare desk s The NGOs provided 5 10 USD/month to reimburse their CHWs' transportation expenses, but did not provide regular remuneration and instead expected them to serve as volunteers I conducted p articipant observation at CHW trainings, meetings, and events, and d uring activities in care recipient homes, nei ghborhoods, and clinics I n this article I focus on observ ations of how the NGOs and government partners attempted to shape their CHWs' motivations and capacities, primarily through discourses emphasizing the emotional rewards of exercising one 's capacities for intimate care After 10 months of participant observation, I began a year long longitudinal survey with 110 CHWs. I recruited a simple random sample of 90 (out of 130) CHWs from th e Hiwot NGO's volunteer rosters, and all 20 volunteer s from the Medhe n NGO Each respondent participated in three waves of surveys over the course of 2008 contributing self reported data on household demographics, socioeconomic status, and food insecurity 1 These data (Table 1) highlight the preponderance of women in the local CHW population (90%), consistent with regional and global patterns acro ss CHW programs (Akintola 2008) Surveys further revealed extremely low household income levels and a high prevalence of moderate to severe food insecurity among the CHWs, as well as a substantial proportion of unmarried and educated individuals in their 20s and 30s, consistent with sociodemographics and economic conditions in Addis Ababa ( Gurmu and Mace 2008 ; Yared 2010). 2


! Table 1: Summary statistics describing CHW survey sample ( n =110) Mean age, years 28 Mean schooling, years 10 Mean number of assigned patients 13 Mean hours per week spent volunteering 15 Median per capita household income, USD/day 0.29 Moderate to severe food insecurity, % 53.3 Female gender, % 90 Marital status, % Married 40.9 Unmarried 33.6 Separated, divorced, or widowed 25.5 HIV serotatus, % Positive 17.0 Negative 72.6 Unknown / untested 10.4 In the surveys, I also asked respondents to identify the two patients with whom they felt closest, and to identify these patients' genders, ages, and ethnic and religious affiliations. 3 By comparing their responses to the data I collected on the CHWs' own self identified ethnic and religious affiliations (data not shown), I was able to demonstrate that CHWs' close relationships with care recipients commonly linked across im portant social dividing lines of ethnicity and religion Finally, I used the survey sample and the data collected at wave 1 to purposively select 13 CHWs (10 female and three male s ) to participate in a series of semi structured interviews over the course of 2008 Each respondent completed up to six interviews which I use here to identify the values and experiences underlying their capacities for empathic and intimate care and to show how their capacities entered into their critiques of h aving to work for free 4 In drawing the purposive sample, I aimed to account for the preponderance of women in the CHW population yet also over sampled men to capture a range of experiences. I also selected participants with varied lengths of service, ages marital statuses, years of schooling, socioeconomic statuses (in terms of food insecurity), and HIV status (Table 2). I conducted interviews in Amharic with help from respondent gender matched assistants unaffiliated with the NGOs involved in the study. 5 CHW Capacities: Values, Desires, a nd Experiences Getting C lose I begin with CHWs' capacity to develop and maintain intimate relationships with stigmatized individuals. This capacity is part ly dependent on r espondents explicit desire to includ e poor and suffering people regardless of their religious, ethnic, or social background within their category of w Š g Š n ( literally, one's clan, faction, or party, but better defined here as fellow people


! ( deemed deserving of intimate care ) For Eskinder, who had recovered from AIDS after beginning antiretroviral t herapy in 2004 treating people with HIV/ AIDS as w Š g Š n was partly about reciprocity: H e had been helped by unrelated neighbors and health professionals, so T oday," he said, "I shoul d make an effort for my w Š g Š n ." Table 2: Pseudonyms and brief profiles of CHWs who participated in in depth interviews Women Fasika 36 years old, married with adult children, teaching diploma, 12 months of service, no food insecurity Rahel 27 years old, divorced mother of three young children, 5 years of schooling, 10 months of service, severe food insecurity Asayech 32 years old, married with one young child, 14 years of schooling, 0 months of service, mild to moderate food insecurity, living with HIV/AIDS Alemnesh 26 years old, unmarried, lives with parents, 14 years of schooling, 0 months of service, no food insecurity Tsehay 22 years old, unm arried, lives with mother and siblings, 10 years of schooling, 0 months of service, no food insecurity Emebet 40 years old, married, 8 years of schooling, 10 months of service, moderate food insecurity Zenebech 33 years old, married, 10 years of schoolin g, 12 months of service, previously volunteered with another NGO, mild to moderate food insecurity Tirunesh 23 years old, unmarried mother of young child, 12 years of schooling, 0 months of service, mild to moderate food insecurity Fikirte 37 years old, married, 0 months of service, previously volunteered as a CHW for another NGO, no food insecurity Mebrat 25 years old, separated from husband, lives with parents, currently attends a private college, 0 months of service, no food insecurity Men Eskinder 35 years old, unmarried, lives with elderly mother, 10 years of schooling, 10 months of service, moderate to severe food insecurity, living with HIV/AIDS Markos 19 years old, unmarried, lives with parents, pursued but did not complete a nursing diploma, 0 months of service, mild food insecurity Alemayehu 33 years old, unmarried, lives with parents, 7 years of schooling, 0 months of service, previously volunteered with another NGO, moderate to severe food insecurity Rahel affirmed, W e are caregivers because we want to help our w Š g Š n ," and reiterated the anti discrimination messages that, according to her, were told in every local religious organization: People with HIV the poor, and the hungry are w Š g Š n Do not discriminate or distance yourself from them. Help them and treat them like w Š g Š n and pray to God." Alemnesh said that "living in harmony with others regardless of social status was a core message of the "spiritual teachings she had internalized and added that her family members praise d her for becoming a CHW and "helping your w Š g Š n with what you have." A common desire to treat people with a highly stigmatized illness as w Š g Š n help s explain


! ) my survey finding that close care relationships created links across ethnicity and religion 57% and 29% of the time, respectively. 6 Such a desire may have encouraged CHWs to care for and become close with care recipients regardless of their ethnic and religious differences. Yet the w Š g Š n idiom admittedly reflect s only an abstract value of inclusiveness and reveal s little about how CHWs forged relationships with care recipients involving mutual expectations and obligations ( see Bornstein 2012). In explaining how they actually establish ed close, trusting relationships with care recipients CHWs often stressed the importance of adopting a deliberate approach one that involved frequent contact patience, humility, and the construction of hope a funda mental challenge shared by broad segments of urban Ethiopian populations (Mains 2011) 7 "The important thing is your approach ," Asayech explained If you go too fast, thinking that you are knowledgeable, they may be un comfortable. If you are careful, and simply visit them frequently and talk with them, you become close." Fasika said that "if you approach them nicely, show them love, and visit them morning and night, they will be yours." T he importance of constructing hope was emphasized by Markos, a young man who in addition to serving as a CHW for several care recipients, had gotten his parents' permission to invite a woman with HIV/AIDS to live rent free in their family's modest home. When Markos met her, she was alone, having trouble ren ting a house, and distraught. C are recipients like this woman Markos said, need to be carefully told by their CHW "I am here for you. You will not stay sick. You will get better and work again." If convinced they will have hope f or the future and be stronger." Keeping secrets ( m • stir t Š bb Š q Š ) emerged as a nother important part of CHWs' capacity to establish and maintain close relationships. "[Care recipients] will become close to you," Markos said, "if you do not tell their secrets." The woman who came to live with his family did so, for instance, only after she had told him "all of her secrets." "She told me everything openly, and I kept those secrets. Then I asked my parents and invited her to live here." In his 1965 ethnography of Amhara ethnic tradition and change, Donald Levine discusses the importance of keeping secrets with close friends in both rural and urban settings. The male students he surveyed in Addis Ababa, who experienced the novel situation of ming ling with peers from various backg rounds described their close friends "as confidants, as individuals with whom they can disclose secrets' and discuss personal problems" (Levine 1965 : 117). The HIV/AIDS care and treatment support program is another novel situation in which relative stran gers build solid re lationships in part by keeping secrets. "I am my patients' confidant ( m•stirŠ––a )," declared Fikirte, suggesting that being a CHW and keeping secrets was an important part of her identity and confirming Rahel's comment that care recipie nts often entrusted their secrets to nobody else but their CHW. CHWs act ed not only as guardians of personal information but also as advocates who divulge d their knowledge when it appeared to be in a care recipient 's interest Tsehay spoke about a father of three young children who had been excluded from the government's food support rosters. She distinguished between the man's outer clothing, which he acquired while employed and which signaled a better economic status to the bureaucrats, and his "inside" lifestyle and history, with which she had become familiar : I was so angry. Because even though he has a good physical appearance, his house and his life were not good. [That is because] he used to have a good job, and he used to have assets b ut he was fir ed from his job when he got sick Eventually I got him and his children to enter the wheat support program by arguing [with the bureaucrats]: "Why do you exclude him? Be cause he wears a leather jacket? D oes


! that mean he has wealth? You can come and see his inside [lifestyle]." CHWs' intimate knowledge of their care recipients' situations was not limited to HIV status but include d various other kinds of personal informa tion, emotions, and experiences. This suggests the relevance of secret keeping and divulgi ng practices to the establishment of close, supportive relationships in other community health worker contexts in Ethiopia beyond HIV/AIDS care In sum, CHWs built and maintained close relationships with care recipients with a deliberate approach and a de sire to see others as deserving of intimate care regardless of background. Reconciliation R econciling conflicts involving difficult questions of stigma and the provision of care and support emerged as a nother important capacity of CHWs relevant to the quality of life of care recipients and their families Several respondents told stories about reconciling spouses some of who m repeatedly fought verbally and physically in front of their children Eskinder told of the time he reconciled a hospitalized 17 year old girl and her aggressive father, who wanted to withhold antiretroviral treatment from t he girl saying, S he should die : I said to her father, Calm down. We don't know from where this child got [HIV]. She could have come in contac t with somebody's blood. He couldn't believe me. His daughter stayed in hospital for more than a month. I was visiting them all that time, consoling the father, and I finally got him to agree with his daughter Now, he has given her a room in his house, a nd she is living properly. The CHWs' involvement as mediators with in care recipients' bio social problems was supported by a wide ly recognized cultural model of conflict mediation and reconciliation known as sh•mg•l•nna D uring my fieldwork for instance, a high profile political drama involving sh•mg•l•nna took place, part of the unfolding of Ethiopia's 2005 election related protests and the state's violent response The government had imprisoned opposition party leaders and supporters, to the dismay of many Ethiopians and international observers. In the months leading up to the Ethiopian Millennium celebrations in September 2007, as reported and read widely in the local press, a group of respected elders mediated a sort of reconciliation be tween the ruling party and its prisoners leading to the latter's release. 8 In more mundane agrarian contexts sh•mg•l•nna is a key role performed by elders reflected in the Amharic term often used for elder : sh•mag•lle One CHW explained however, that T oday, one does not have to be old to be a sh•mag•lle. My respondents further connected reconciliation to values of peace and the emotional and spiritual benefits experienced not only by the reconciled parties but also by the reconciler friends, and f amily "If it is within your capacity," Rahel affirmed you must try to reconcile people w hen you see them separated." Reconcili n g others was so desirable, Tsehay explained, because it meant pleas ing God and prevent ing Satan ( sŠytan ) the embodiment of hateful feelings from separating people: "God says, Above all, r econcile others and give love.' Why? To cool the sŠytan between people ." Mebrat said she found happiness in the fact that her father's skillful arbitration was frequently sought by relatives and neighbors "He is not highly educated, she pointed out, but he simply


! + has a nature of convincing others." Eskinder reflected that "When you reconcile others, you will give them happiness, and you will also be satisfied. You will be blessed. He recounted that when he recently met the hospitalized girl mentioned above, she told him Now I agree with my father and I love him. He gave me a room where I can live and eat, and he gives me money. " For me, Eskinder asserted, that is big happiness." CHWs thus exercised an important capacity to effectively reconcile conflicts within the ir care recipients social networks which did not require elderly status or formal schooling but rather a desire to generate and experience the emotiona l benefits of reconciling others, sensitivity to the desires and concerns of the conflicting parties and patience Confronting D eath The capacit y to help stigmatized patients have "better" deaths is partly illustrated by CHWs' comments about adŠra : the entrustment of something or someone to another's care at the time of death. While someone's adŠra is typically handled by a close relative, Rahel affirmed that patient s often chose CHWs to take on their adŠra b ecause of the key role they played in th eir care: "They say, You were there for me while my relatives were not.'" Rahel also described adŠra as a potential burden: H ere, you are not afraid of death, but you are afraid of the adŠra. It is very heavy, and it is not good for your mind." Neverthel ess, she and Eskinder each spoke of accepting the adŠra of care recipients by securing care for their children or selling a possession to settle a debt out of a sense of obligation and a desire to ease their worries Many CHWs also spoke about providing patients with better deaths by carefully preparing their corpses for burial a salient experience for CHWs due to the emotional and physical difficultie s involved Asayech narrated a specific experience in which she was called to att end to the death of a patient who lived in her neighborhood: The woman's bed was soiled Her mouth was open, and her body had sores. I saw all of that when we were washing her body. And though men usually put the body in a coffin, I did that. Let alone the things that you touch, the smell will hurt you deep inside. If you see the work deeply, it is difficult. It is not simple. Mebrat recounted how her first confrontation with a dead patient led to a great deal of embodied stress : "My body was shakin g the whole day. For several weeks I was waking up in the middle of the night and couldn't sleep. I lost weight After 11 months of experience, she admitted that she was still in the process of adapting to the emotional challenges presented by caregiving Such adaptation apparently happened. Several CHWs told stories about becoming able to fearlessly prepar e the bodies of patients who had died through either repetition or specific experiences Eskinder said he used to have "the fear" when he first became a volunteer CHW. But over time, he said, I got used to it, because I see dead people every day." Rahel said she got over her fear thanks to her first experience with a dead patient which occurred in a hospital ward: It is better if I learn than this woman 's body gets spoiled," Rahel told herself. With ano ther volunteer and the nurses, she prepared the woman's body. Rahel said: After that, I was no longer afraid. Tsehay recounted a specific experience in which she was called to attend to the death of a wo man in her neighborhood. After several difficult hours of the woman's soul


! ", "leaving her and co ming back again," she finally died. "We prepared her body and put her into the coffin. After this, I stopped fearing death. An experience like that makes you brave." Underlying this capacity to provide patients with better deaths were Christian models of God's nondiscriminatory love, a belief that God gives life and death to all humans equally, and desires to please God Eskinder connected t he w Š g Š n idiom to his willingness to attend to the deaths of patients : "When people are convulsing, gasping, and falling from bed," he said, "we [CHWs] correct it. We pick them up and pr epare them. We wash them and we bury them. Why? They are w Š g Š n." Finally, Fasika provid ed a narrative illustrating how these religious and pro social beliefs could be reinforced within CHWs' families. S everal years back in her hometown in north ern Ethiopia, Fasika's mother had taken in an HIV positive man who had been thrown out of a neighbor's house. "My mother said, Bring him he can lie down in my home. My house belongs to Medhane Alem [literally Savior of the World ( i.e. Christ ) ] .'" While caring for him, Fasika' s mother contracted H IV, developed AIDS, and died When Fasika first became a volunteer CHW, a young woman near death was assigned as her patient She was told that the woman had a history as a sex worker in Djibouti before falling ill and returning to Addis Ababa When Fasika visited the woman, she found her lying naked in a back room of her brother's house: Her brother and his wife were there, but nobody was putting clothes on her. She was al one. Everybody else had retreated. Fasika said she envisio ned the patient dying alone, and asked herself Who is going to prepare this woman's body? My mother died because she was taking ca re of what my people threw away. How can I do nothing when I see the dis ease attacking so many people? In this particular s ituation and in the daily experiences of Fasika and her fellow CHWs, the alternative to doing nothing was to exercise several capacities to provide intimate care to people with HIV/AIDS. Harnessing CHW C apacities Institutional E ncouragement F HI 's 2007 report to its primary funder, USAID, estimated that its local NGO implementing partners had trained over 11,000 volunteers acros s Ethiopia for home based care and antiretroviral treatment support. The report further states that during early phases of its urban home based care program s NGO s the government, and donor partners were "keen to harness the good will and generosity of [Ethiopian] communities to meet their goal of improving the quality of life of patients and their families (FHI 2007:72). B y elucidating specific CHW capacities and the constellation of values, desires, emotions, and abilities that comprise these capacities, so far I have attempted to develop a better understanding of the "good will and generosity" and human dignity that HBC p rograms sought to "harness" during a rapid scale up of access to antiretroviral therapies. A s the metaphor suggest s harnessing these CHW capacities involved NGO and government efforts to shape and encourage these capacities The WHO (2002) recommended such efforts in its global "framework for action" on HB C in "resource limited settings Thus a t a ceremony held in Addis Ababa's city hall, CHW recruits of the Hiwot NGO swore a public oath lit candles in hand to keep the secrets of care recipients p rovid e good care and put care recipients' needs before their own T he Me dh e n NGO reinforced t he w Š g Š n idiom when Eskinder and his fellow volunteer recruits were sworn in : "Our supervisors made us promise on


! "" the Bible when we entered this place. To serve and respect our w Š g Š n .' We promised that R econciling patients' conflicts and attending to deaths were encouraged and modeled too D uring the second week of training for 50 new recruits of the Hiwot NGO five trainees including Fikirte performed a short social drama in which the father of a household reveals to his family that he has tested positive for HIV and it takes a neighbor to carefully bring the household members to a mutual understanding In one of our interviews, Rahel narrated how she and he r fellow recruits also received experiential training in preparing dead bodies through simulated practice on each other, meant to t each them what to do and reinforce their convict ions that people with AIDS deserved such care These examples illustrate how the institutions that called on the CHWs attempted to shape and encourage their capacities to provide compassionate and intimate care for marginalized people in life and in death with an explicit goal to improve the quality of life of patients and their f amilies At the same time, this public health program also expected CHWs to engage in unpaid "vol unteer" service FHI wrote in its 2007 report to USAID that, "The level of interest and commitment of volunteers to the [HBC] program has been overwhelming The program has shown the untapped spirit of volunteerism that exists within Ethiopian communities despite such pervasive poverty" (FHI 2007:52). But volunteer spirit did not simply flow. Rather, in a context of widespread unemployment and food insecurit y, institutions keen on harnessing CHWs' capacities found it essential to mobilize certain discourses to get them to accept their subordinate status as unpaid volunteers within a hierarchy of paid staff. Institutional J ustifications and CHW C ritiques o f V olunteerism" At a 2008 CHW recognition event, organized primarily by the Hiwot NGO with funding fr om F HI an officer from FHI gave a speech in which she claimed that the volunteers were "happy" to walk through muddy slums, to "give their time for the patients instead of taking care of themselves." Later during the same event, the director of the Hiwot NGO delivered her address, in which she bestowed great praise on the CHWs and compared them to candles, giving light and hope to their patients while me lting away in self sacrifice. A poster taped to a wall in the main office of the Hiwot NGO claim ed that "Volunteers are not paid not because they are worthless, b ut because they are priceless." These discourses are similar to ones seen in other volunteer C HW contexts, in which high status, salaried health officials express concerns that so called extrinsic rewards like wages will "ruin" or "crowd out" the intrinsic motivations values, and religious beliefs that underlie CHWs' capacities ( Glenton et al. 2010 ). Such discourses raise questions about what CHWs think of their motivations and of their contributions to global health programs that move and distribute many kinds of resources across the globe. On the one hand, t hese discourses were apparently suc cessful in shaping CHWs' political subjectivities motivations and capacities For example, when asked whether being a CHW involved sacrifice, Alemnesh agreed, brought up the melting candle metaphor she heard at the CHW recognition event two weeks prior to our interview, and said that it had deeply influenced the way she thought about her work. Eskinder lamented that volunteering did nothing to alleviate his poverty, which he identifie d as rooted in a lack of employment and rapidly rising food costs : "Nowadays, life is simply expensive and there is no employment Yet he also said that he would continue to volunteer as a CHW because, as he put it, I t is a promise." Alemayehu, who exper ienced recurrent insomnia in addition to several sym ptoms of psychological distress which he related to his inability to support his family with a good job s aid that he still planned


! "$ to continue volunteering, which he saw "a s an obligation, as citizenship CHWs also often told me that their principal benefit was a sense of happiness and "mental satisfaction." On the other hand, during interviews these CHWs also oppos ed the expectation that th ey sacrifice and exercise their capacities in return for mental satisfaction only In so doing, they often emphasized the quality of their service in terms of close and compassionate engagement with care recipients. For instance, I interviewed Alemnesh as she prepared to leave the CHW program to take a job opportunity in Dubai, 10 months before completing the 18 months expected by her NGO She had not yet informed her NGO supe rvisor because, as she put it, she was afraid and knew that her supervisor depended on her. When asked how she f elt about leaving the program, she answered the question as if she were defending her decision t o her supervisors: When they recruited me, I told them I would work as long as I am here [in Addis Ababa]. I served eight months, and I am very, very close wit h the patients, [especially] with the children And it is difficult [to leave ] but it is life. T o feel confident and unselfish in making the decision to leave her volunteer position to work abroad, Alemnesh emphasized her close e ngagement with care recipients, not her dutiful efforts to submit forms and reports. She also suggested that a desire for better employment is simply a fact of life for young women in Addis Ababa Eskinder provides a nother example He complained that his N GO had stopped providing food stipends (sacks of wheat and cooking oil) to its volunteer CHWs. We respected our word [to care for others], and our supervisors should respect theirs [i.e., to support the volunteers]," he affirmed. "They are reducing things, but we are not reducing our love." In the absence of other job opportunities, Eskinder declared that the NGO had a responsibility to provide better material remuneration. By emphasizing that he and his fellow CHWs were maintaining their "love" for their care recipients, he avoided appearing selfish for desiring better remuneration from the NGO. Conclusion: The V alues of CHW L abor A nthropologists interested in international development are challenged to analyze the transnational webs of "funds, energies, and affect" involved in 21 st century social assistance programs, and to consider the progressive possibilities of such programs while keeping an eye on how they address job creation as a means to reducing poverty and improving quality of life (Fe rguson 2010:169) Recent ethnographic studies have analyzed the rationalization of unpaid labor, primarily women's labor, within CHW programs (Akintola 2008; Maes 2012), and the motivations of pseudo volunteer CHWs in search of socioeconomic advancement ( K aler and Watkins 2001 ; Swidler and Watkins 2009). In addition, researchers have shed light on why CHWs sometimes lack solidarity with the people they are supposed to serve (Abbott and Luke 2011 ; Le Marcis 2012 ; Mumtaz et al. 2013 ; Wayland and Crowder 2002 ) T he ethnographic case examined here elucidates the capacities exercised by CHWs to provide intimate care to beneficiaries of an antiretroviral therapy program put forth through partnership among local NGOs, government offices, and community organizations, a na tional hospital, and a multitude of international NGOs and donors This kind of ethnographic microanalysis of CHWs' capacities helps explain why and how p eople in urban slums build positive and solid relationships across social dividing lines like religious and ethnic affiliations and health statuses an important aspect of what social epidemiologis ts call bridging social capital ( see UN HABITAT 2008 :200 ). I t also helps explain how local government and NGO


! "% institutions value these capacities in terms of treating them as central to a goal of provid ing patients with better quality lives in addition to biomedical treatment It is important to recognize that the CHWs I encountered in Addis Ababa did not experience solidarity and intimacy with all of their intended beneficiaries. In fact, Rahel recalled meetings between her cadre of CHWs and their supervisor, in which some CHWs spoke openly about not wanting to visit the houses of people who "don't give us a kind face Markos and Asayech also distinguished between care recipients who greet CHWs nicely, openly discuss their problems, and "care for themselves on the one hand, a nd others who "do not have good behavior," "do not listen to what we tell them and "give up taking their medicine," on the other. These kinds of comments resonate with ethnographic observations elsewhere in Africa of the behaviors and sentiments that pe ople living with AIDS must display to become and remain deserving of scarce resources and care in the eyes of support groups and NGOs (Kalofonos 2010; Nguyen 2010; Prince 2012) But in this particular context, it would be inaccurate to claim that these comments reveal a bureaucratic and unfeeling directive to promote and monitor disciplined adherence to pharmaceuticals, handed down to CHWs from the institutions that deploy them. In his ethnography of Aghor healers and disciples in northern India, Barret t (2008) proposes that, although humans may have a universal tendency to stigmatize social deviants out of fears of decay and social death, we may be able to bypass this tendency and engage our capacities to care for stigmatized others through ritualized, patterned confrontations with death and decay ( see Dijker and Koomen 2006) Similarly, Klaits (2010) proposes that religious institutions like the Apostolic "church of life" he studied in Botswana can impress on its congregants a moral imperative to love shelter, and comfort sick people who have been abandoned by kin. Unlike Aghor disciples, the CHWs and institutions I encountered did not go so far as to prescribe rituals for overcoming death fears as a means to achieving a psycho spiritual state of radica l nondiscrimination. But like Aghor disciples and Apostolic church congregants in Botswana, volunteer CHWs in Addis Ababa during the initial years of antiretroviral therapy roll out actively drew on shared values that were discursively and ritually reinfor ced to actively confront discrimination and death amid intense poverty and everyday forms of exclusion and violence. Indeed, CHWs here recognized and attempted to curb their discriminatory tendencies. Rahel claimed she countered talk of unkind care recipi ents among other CHWs by telling them, I t could be because of your approach. You have to give good love for them in the first place." And Markos was reluctant to blame those patients with whom he and his fellow CHWs did not become close, explaining, "They are thinking a lot about their problems and their disease. So you should avoid your negative perception of these patients, and try to be kind." The CHWs I encountered thus tried to maintain their capacities to confront discrimination and exclusion partly because the institutions that deployed them were encouraging them to do so In the ethnographic context presented here, CHWs were also encouraged by government and NGOs to feel a sense of religious and civic duty to exercise their capacities to improve the lives of others, to beli eve that sacrifice was a central part of the position, and to seek primarily emotional and spiritual rewards for exercising their capacities. T he institutions that deployed these CHWs avoided valuing their labor in the sense of providing regular remuneration to improve a major aspect of their own quality of life. CHWs in this context perhaps contributed to their own lack of remuneration by expressing their willingness and happiness to donate their social and emotional labor to im prove the well being of others Y et they also critiqued the


! "& expectation that they serve without pay and expressed desires for better job conditions and socioeconomic advancement In doing so they, too, highlighted their capacities for compassionate engagements with care recipients affirm ing the importance of the intimacy they shared with wŠgŠn and perhaps defend ing against being labeled as selfish These comments represent the constrained forms of criti cism and self advocacy in which CHWs can engage, in the absence of any sort of autonomous CHW association and in the presence of strong discourses emphasizing the moral duty of CHWs to sacrifice in the name of humanitarian goals ( see Maes et al. 2014) CHWs are at work in various contexts throughout the world. The AIDS focused, NGO deployed CHWs I studied in Addis Ababa stand in sta rk contrast, even, to the "generalist" CHWs known as health extension worker s who were concurrently being deployed in rural Ethiopia and paid a salary by Ethiopia's government (FMOH 2007 ; Teklehaimanot and Teklehaimanot 2013) Globally, CHW advocacy for more and better paid positions for themselves will surely evolve to take on new forms at local, national, and perhaps transnat ional level s A cross CHW programs there will also be much variation in the specific capacities that CHWs exercise, and the values attributed to CHW labor and capacities, furthermore, are under negotiation and evolving. Positive change within global CHW programs in which CHWs improve the quality of life of others while global health institutions encourage and pay them to do so I suggest, will depend on ethnographic analysis of these interrelated dynamics Notes 1. I trained and closely supervised fou r Ethiopian research assistants to collect the survey data The research assistants worked in pairs to maximize data quality. $Detailed descriptions of how these constructs were measured can be found elsewhere (e.g., Maes and Shifferaw 2011). 3. The Amharic adjective q•rb was often used to describe close relationships between people as well as geographical distances Preliminary ethnographic work made it clear that most CHWs built close relationships with multiple but not all of their assigned pat ients. Two was chosen to limit response burden. Response categories for ethnicity were : Oromo, Amhara, Tigre, Gurage, Other. For religion: Orthodox Christian, Protestant, Muslim, Other. &Longer narrat ives on the lives and desires of these respondents can be found in other published articles ( Maes 2012; Maes and Kalofonos 2013 ; Maes and Shifferaw 2011 ). 'Transcribed interviews and field not es were coded in MAXQDA usin g a coding scheme combining pre determined and in vivo codes. I worked closely with my assistants to translate the interviews, discussing intended meanings. 6. In 8% and 2% of cases CHWs were unsure of their close patients' ethnic and religious affiliations, respectively. 7. The Amharic term used for approach (noun: m Š qqar Š b ) is related to the ad jective q•rb Since I posed the question in general terms, responses did not always refer to the close relationships that respondents identified during surveys 8. This narrative was presented in an article in the Christian Science Monitor ( Halpern 2007 ), and reprinted on August 12, 2007 in one of Addis Ababa's English language weekly newspapers ( Fortune Volume 8 N umber 30).


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