Kaufman, MD, is the vice chancellor for community health
at the University of New Mexico (UNM) Health Sciences
Center and is a distinguished professor of family and
community medicine in the UNM School of Medicine (SOM).
Kaufman launched educational innovations that placed
medical students in clinical roles in underserved areas.
Kaufman also helped create UNM's Health Extension Rural
Offices (HEROs) program, based on the agricultural
extension model, which assigns HERO agents throughout the
state to serve as community liaisons with the UNM Health
Sciences Center. In addition, Kaufman helped spearhead
the "Beyond Flexner" movement, a
national effort to change how academic health
centers address social determinants that play a
pivotal role in health risks and outcomes. In 2015, he
was elected a member of the National Academy of Medicine,
formerly the Institute of Medicine. Recently, UNM SOM
recognized Dr. Kaufman as its 2018 Living Legend,
creating the Arthur and Ellen Kaufman Endowed Chair in
his honor. He has written four books and authored over 70
publications and has received numerous federal and
private foundation grants. Kaufman's wife, Ellen, and
their two children are also physicians.
Recently, we spoke about the role that HERO agents have
played in his state and beyond, how he is helping push
the visibility and use of community health workers, and
his work with UNM's World Health Organization
What sparked the idea for Health Extension Rural
"Health extension" is an idea we
borrowed from the agricultural Cooperative Extension
Service. There were two appealing aspects of the
Extension Service – they addressed social determinants of
disease and they were a model of the diffusion of
innovation from land grant universities to frontline
farmers and farm families. For example, Cooperative
Extension agents help increase nutrition education
through its Family and Consumer Sciences, help youth with
school success via its 4-H clubs, and help farmers
increase crop yields though university science labs.
Further, if an agricultural college discovers a better
growing technique or a new way to treat fruit tree
infestations, community-based Cooperative Extension
agents can move that knowledge quickly to frontline
farmers. And if an extension agent in a community sees
one farmer devise an innovative best practice, the agent
can promptly share that practice with other farmers in
the region or state. That was our role model and it's how
we started putting HERO agents all over the state. It's a
model that has now been emulated in many states.
Beyond adopting the Cooperative Extension idea into
health, we now have a growing partnership with
agricultural extension in New Mexico. This is facilitated
by the major changes in the U.S. agriculture industry.
With mechanization, the agricultural workforce is
shrinking, so Cooperative Extension is seeking to
redeploy much of their workforce toward health – and we
What do HERO agents do?
Their role is to connect the priority health needs of
their regions with university resources. We started with
UNM Health Sciences Center resources, but we learned in
the last couple of years that we have many more resources
in the university that can help communities – for
example, the colleges of engineering and of architecture
and planning. We have developed a model that is driven by
community needs rather than university needs – that's
what health extension facilitates.
What does the day in the life of a HERO agent look like?
It varies with the geographic area. It's designed around
what communities want. Some HERO agents are tackling the
deficit in behavioral health services in the state by
putting on Mental Health First Aid classes for laypeople.
Some are helping communities write grants, and some are
working on changing health policies. Many are helping in
primary care practice transformation to meet the
Affordable Care Act goals. One agent just helped start
the first school-based clinic in the southeast corner of
the state, near west Texas.
HEROs help move the locus of control from the university
to the community.
HEROs help move the locus of control from the university
to the community. HERO agents are instructors and receive
faculty appointments at UNM. People recognize the value
of having this resource and access to the resources of
the university right at their front door.
We currently have 10 HERO agents but are looking to
eventually hire 20 to cover the state adequately. New
Mexico is the fifth largest state in size, but it's
sparsely populated. With too few agents, they spend too
much time on the road.
How have HEROs evolved and how will they evolve
in the future?
Our work is in three mission areas: education, service,
and research. We spent much of our initial years focused
on educational innovation to get more medical graduates
into rural and underserved areas because of the desperate
access issues in our state. Over time, it became clear
that that effort is not sufficient. You can train very
eager, well-prepared health providers for rural and
underserved areas, but they might enter healthcare
systems that are inhospitable to a focus on primary care
and community health, incented more to build subspecialty
referral bases. So that's the first big shock – we'd
better expand our focus to innovations in clinical
service. The second major issue was that, when you look
at the healthcare system, you realize it has so little
impact on health. A major reason the U.S. lags so far
behind all the other Western countries in quality of
service and health outcomes is we spend so much more on
clinical services and so much less on social services.
Adverse social determinants play a major role in health,
and that would be served by the social services component
of a health system. The question was whether we could
take some of that "downstream"
clinical service money and re-allocate it
"upstream" to address social needs
like transportation, nutrition, poverty, and housing.
HEROs were one answer to this question.
What other resources are you using to address
social determinants of health?
Our biggest and newest program that is expanding rapidly
is around community health workers (CHWs). They address
social determinants at the individual level, whereas
HEROs address them at a regional or county level. HERO
agents are more masters-level trained, and CHWs only need
to have a high school education. Their skill is defined
not by degrees on their wall but by their intimate
knowledge of their communities, their cultural and
linguistic competence, and the trust their communities
have in them. They can also quickly identify social needs
in their patients, they know a myriad of resources, and
they have the ability to screen for and address adverse
social determinants. We've now linked them so that we
have HERO agents training CHWs in different areas of the
state, bringing these two important systems together.
How have HEROs been funded?
When the ACA was being written, our UNM Office for
Community Health and the Department of Family and
Preventive Medicine at the University of Oklahoma wrote
Section 5405 of the ACA, entitled Primary Care
Extension Program. The Senate Health, Education, Labor
and Pensions (HELP) Committee, chaired at the time by
Senator Ted Kennedy, was interested in the concept of
health extension. We already had been developing health
extension for a number of years before the ACA. The
committee writing the ACA thought we might use extension
to help improve the quality and efficiency of primary
care practices and also help those practices to improve
The Agency for Healthcare Research and Quality (AHRQ) at
the time put $4 million into the
IMPaCT grant to pilot primary care extension, with
New Mexico receiving one of these grants. After the
success of IMPaCT, AHRQ invested $112 million into the
next grant, EvidenceNOW,
creating seven cooperatives all over the country, each
supporting primary care transformation for at least 200
small to medium-sized practices involving eight million
…if health extension is going to be successful, it has to
be sustained by state and local funding. Federal and
private grants are important in helping test innovations,
but they're only a start.
The idea of health extension is growing, partly through
federal grants, but private foundations also have
contributed. The dissemination was given a big boost by
the Commonwealth Fund, which funded development of the
online Health Extension
Toolkit, a vehicle for showcasing the health
extension work of 16 programs. For me, if health
extension is going to be successful, it has to be
sustained by state and local funding. Federal and private
grants are important in helping test innovations, but
they're only a start. Institutionalization usually
requires sustained funding by those who receive benefit
from the innovation—health systems, public
What is the Health Extension Toolkit and how does
it tie in with HEROs?
The Toolkit was a way for us to update our partners and
present evidence with the material we've used. We want to
share what we have and needed a universal perspective of
looking at data. How do you mobilize an academic center
to address social determinants? You hire agents around
the state and mobilize around this vision, deploying
resources a different way. Health extension is our
cutting edge to get there. When you have agents in the
community telling you, "You don't have enough
nurses in the community, mental health problems here are
horrendous…" all of these were addressed
community by community. That's the genesis of an online,
freely accessible toolkit to offer different approaches
to implementing health extension, with lessons learned
from different states.
Do you collaborate with other groups besides
Cooperative Extension? And has there been any resistance
to HEROs from other organizations?
Each step of the way there was resistance because we were
treading on other people's area of expertise. Whether
it's the Area Health Education Center (AHEC) or
Cooperative Extension, they feared we would receive
funding and notoriety that rightfully belonged to them.
But, as we worked together, fear subsided and our
mutually supportive and complementary strengths became
apparent. AHEC was originally, primarily, an educational
pipeline development program. But the newest iterations
of AHEC grants nationally included expectations of
greater connection with clinical service, a role more in
line with health extension. In addition, both the HEROs
program and the AHEC program are now under our office. We
have three AHECs in New Mexico, and those three AHEC
directors wear a second hat so that they are also HERO
agents. The overlap and collaboration is so high that it
works very well.
Early on, some in the Department of Health were also
skeptical of HEROs, seeing them as little different than
the Department's Health Promotion Specialists. Over time,
we iterated that HEROs had a special connection with the
resources of the University of New Mexico, just as
Promotion Specialists accessed resources of the State
Department of Health. Today, public health is becoming a
stronger ally as we both struggle to address health
inequities in our state.
How are community health workers forging a
stronger relationship with HEROs and other organizations
in your state?
CHWs are known, trusted, and able to move nimbly in
different community circles based in part on their
cultural and linguistic competence. To complement their
role in communities, when you put CHWs in the middle of
clinics and hospital services, it allows the health
service system to understand firsthand the importance of
screening for and addressing adverse social determinants
affecting the health of patients. This strategy is linked
to health extension, for HERO agents train and work
collaboratively with CHWs in their region.
Having CHWs embedded in clinical settings has been
transforming for our clinics. CHWs are a popular new
addition there because they take the most difficult
problems off the plates of providers. They help get
patients into the social services they need, for example,
getting new mattresses for patients who have bed bugs or
getting people enrolled in GED classes. In the past, we
would never have asked about adverse social determinants
since we didn't have the resources to address them.
Clinic-embedded CHWs have brought great cost savings to
the clinical enterprise. Now that we have this model,
many organizations are adopting it. Besides hospitals and
clinics, Medicaid managed care organizations all over the
state now have CHWs working with their highest-risk
patients and are reducing costs. The state's largest
county jail is employing them to reduce recidivism. And
they are populating nonprofit social service agencies.
Today, we screen every patient who comes into primary
care clinics at UNM and at the county's largest Federally
Qualified Health Center, First Choice Community
Healthcare. We've screened over 25,000 already. We found
that one of patients' top unmet needs was for help in
paying their utility bills. While CHWs have easy ways to
get utilities paid for, their greatest challenge is
finding housing for needy patients. When you are in
Santa Fe or Albuquerque, you might have a wide array of
resources. But in a rural or frontier community, you have
to be in the business of generating those resources if
they don't exist. In bigger cities, CHWs might be
differentiated – some working in hospitals, others in
community agencies. But in smaller towns, our CHWs are
broadly trained and not differentiated.
What does the WHO Collaborating Center do, and
how does it draw on your other interests such as social
determinants of health?
New Mexico is one of the poorest states. Ours is a public
academic health center that has tried to mobilize its
programs in education, service, and research to address
state priority needs. This was of enormous interest to
the World Health Organization (WHO), for the vast
majority of schools in developing countries train
physicians who leave their countries or serve wealthier
clients in bigger cities – very few go into rural or
underserved areas. In the U.S., you see the large
research institutions that also don't adequately address
priority community health needs. So WHO became interested
in sharing UNM's model with other countries. One
component of that interest was our designation as a WHO
Collaborating Center focused on health workforce
development for local needs.
The designation leads to an expectation that WHO and its
regional Pan American Health Organization would send
leadership from schools in developing countries to look
at models we've created here and have us put on workshops
on our models and also on how to create institutional
change. In addition, members of our team visit interested
institutions in other countries. We are also a
beneficiary of this designation, as we are able to adapt
important innovations we see abroad to our own
institution and state. These models include
community-based learning, recruitment into the health
professions from rural and underserved ethnic
communities, and broader use of CHWs as a tool for
improved community health and economic development.
There was a study done in South Africa that showed if a
doctor is trained in a developing country but leaves to
work in North America or Western Europe, that developing
country lost the $150,000 investment they made in
training that doctor. But as a recipient of that doctor,
North American or Western European countries save
$450,000 that they didn't have to invest in their
training. Such a brain drain represents a massive subsidy
of the wealthy by the poor.
What led you to leave NYC, where you grew up and
where you received your medical training, for New Mexico?
Did you always want to live in the Southwest?
It changed my life. I … saw the devastation wrought by
adverse social circumstances on my Native American
patients, and I changed my career to primary care and
I sought an alternative to the draft as a Vietnam War
protester and was selected to work in the Indian Health
Service in South Dakota, then New Mexico. It changed my
life. I planned to become a NYC psychiatrist but saw the
devastation wrought by adverse social circumstances on my
Native American patients, and I changed my career to
primary care and community health. My wife, also a
physician, and I fell in love with New Mexico. We've been
here 43 years.
Opinions expressed are those of the interviewee
and do not necessarily reflect the views of the Rural
Health Information Hub.