大象传媒

All Nirmal Singh and his wife, Daljit Kaur, wanted were a few groceries from Walmart.

But as the older couple drove in circles around the suddenly unfamiliar streets of Fresno, California, Singh feared they鈥檇 be spending the night in their car. 

Singh, 72, had struggled with bad eyesight for years. At the meatpacking plant where he works the night shift, he strained to see the hooks for hanging chickens and worried he might trip over stray pieces of meat on the floor. His wife鈥檚 eyesight was even worse. Kaur, 69, fell frequently because she couldn鈥檛 see obstacles and uneven ground in front of her. She once had to go to the emergency room after hitting her head and spraining her wrist in a fall.

Neither could see street signs well enough to read them. Singh had memorized the routes to work and the supermarket. But on this Sunday, a few months ago, road construction blocked the exit to Walmart. Signs directed drivers to an alternate route. At one junction, a sign said turn right. Singh turned left. He soon realized he was lost.

鈥淚 was worried,鈥� Singh said through a Punjabi translator during a recent interview at the rental apartment he shares with Kaur. 鈥淚 didn鈥檛 know what to do.鈥�

Singh and Kaur are among an estimated 50,000 immigrants and their descendants from the Indian state of Punjab living in Fresno, and one of the largest ethnic groups in the Central Valley. They鈥檙e an important part of the region鈥檚 agricultural workforce, laboring in fields, packing plants, and the trucking industry. While some Punjabi residents own farmland or other businesses and have built successful careers, others鈥攑articularly older and more recent immigrants working low-wage jobs鈥攕truggle to access critical health services and basic necessities. Like Singh and Kaur, they sometimes live with ailments such as poor eyesight and tooth decay, or diabetes and kidney disease without getting the care they need.

Into the void left by a health care system that doesn鈥檛 offer sufficient translation services and an economy that demands grueling labor from low-wage agricultural and meatpacking workers, Punjabi residents have created an organization to help each other. The Jakara Movement, a nonprofit founded by local Punjabi Sikh residents, has a team of five community health workers who visit Sikh temples (known as gurdwaras), community events, and Punjabi-populated neighborhoods to talk about ways to better manage health challenges and assist in accessing health care and other services. Since launching the program in 2020, the workers have organized over 41 health resource fairs, shared information at dozens of community events, taught more than 90 workshops on health-related topics, and helped at least 4,000 people with issues ranging from enrolling in Medi-Cal to obtaining nutritious food to understanding how to ask for an interpreter at the doctor鈥檚 office.

Punjabi people trace their lineage to the Punjab region of modern-day India and Pakistan. For more than a century, Punjabi residents have lived in California鈥檚 Central Valley, often laboring as farmworkers and sometimes establishing farms themselves. More recent Punjabi immigrants often settle in the Central Valley because of family ties and work opportunities. A majority of those living in the region are members of the Sikh religion, although some practice other faiths, including Hinduism or Islam. The Jakara Movement鈥檚 community health worker program is led by Punjabi Sikh residents but assists people of other faiths and ethnicities too.

Like other immigrant communities in California, Punjabi residents face numerous barriers to achieving and maintaining good health. Those in low-wage jobs often struggle to afford healthy food and adequate housing. They may not have money to pay for medical care or transportation to get to doctor鈥檚 appointments. Some don鈥檛 have health insurance, or the coverage they get through their employer is inadequate. Stress from working long hours or multiple jobs can also take a toll on their physical and mental health.

Language is another obstacle. About half of Punjabi speakers in California don鈥檛 speak English well, according to Naindeep Singh, Jakara Movement鈥檚 executive director. (Naindeep Singh uses the same last name as Nirmal Singh but is not related. Members of the Sikh faith often use the last name Singh if they are male and Kaur if they are female, as a rejection of the Indian caste system and a symbol of unity and equality.) Information on state and federal programs such as Medi-Cal, Covered California, and USDA farm worker relief grants isn鈥檛 offered in Punjabi or is poorly translated, Naindeep Singh said. Health insurance letters and bills are often sent in English, requiring the recipient to call a helpline if they need translation. Even when writing is in Punjabi, which uses a different writing script than English, some community members can鈥檛 make sense of it because they do not know how to read or the language is too formal.

Finding Punjabi-speaking medical providers is also difficult. Community members often don鈥檛 realize they have the right under state law to request interpretation for medical appointments or ask for translations of health documents, said Mandip Kaur, Jakara Movement鈥檚 health program manager. Even calling to ask for interpretation can seem daunting.

Some rely on English-speaking family members to help them navigate medical care. But not all community members have access to this kind of help. Many also feel ashamed to ask for assistance from people outside of their community or fear they might be scammed or face discrimination, Mandip Kaur said.

鈥淲hen you talk about overall health and knowledge, the biggest, biggest [barrier] is language access,鈥� she said. 鈥淚t鈥檚 one of the reasons we have a lot of community members come to us to make phone calls for them, dispute billing for them.鈥�

For Nirmal Singh and Daljit Kaur, not speaking English makes many aspects of life difficult. On the day they got lost on their way to Walmart, they drove around for two hours trying to find a Punjabi person to ask for directions because they didn鈥檛 know how to communicate their predicament to an English speaker.

It was one of the reasons they hadn鈥檛 sought help in Fresno for their vision problems either. How would they find an optometrist, they asked, let alone communicate with an English-speaking provider? The other problem was financial. Nirmal Singh鈥檚 employer-sponsored health insurance doesn鈥檛 cover dental or vision care. He couldn鈥檛 afford to pay for an optometry visit out of pocket.

That Sunday in the car, the couple did eventually stop an English-speaking passerby because it was getting dark and they couldn鈥檛 find a Punjabi resident. Nirmal Singh pointed to his address, which he keeps written on a piece of paper in his car, for just such a situation, and the passerby drew them a map. Ten minutes later, the couple pulled up to their apartment. Their vision problems, however, remained unresolved.

By and for the Community

The Jakara Movement鈥檚 community health worker program began during the pandemic. Before that, the organization, founded in 2000, focused mainly on youth leadership and development at high schools and colleges throughout the state.

But the pandemic pushed the organization to expand its focus. Fresno County hired the Jakara Movement to help with contact tracing of Punjabi residents exposed to COVID-19 and to educate people about the virus and how to protect themselves. Later, the Jakara Movement helped organize and translate at vaccine clinics. With support from the city of Fresno, the nonprofit also assisted community members in signing up for rental assistance and government aid for people working in the food industry. At the height of these efforts, the organization had about 20 community health workers.

But there were community members still waiting for help. People began coming to Jakara staff members with questions about non-COVID health concerns, how to access medical care in Punjabi, submit medical bills and paperwork, and resolve labor issues. Many didn鈥檛 understand their health care rights or were misinformed because there was so little reliable information available in their language.

鈥淐OVID brought up this whole other world of 鈥楬ow do we help our youth if we don鈥檛 help their families as well?鈥欌�� Mandip Kaur said.

With a grant from the city, the Jakara Movement launched a health literacy program. Community health workers set up tables at local gurdwaras where they offered information in Punjabi about managing ailments such as diabetes and hypertension, translated health documents, signed people up for Medi-Cal and other government programs, and answered questions about finding medical care, dealing with wage theft, and resolving immigration issues. They held workshops in Punjabi on navigating the health care system, healthy eating, asthma, heat illness, and mental health.

Word of the assistance soon spread. Inderjeet Singh Brar, 55, got help signing up for rental assistance and Medi-Cal, allowing him to stay housed after he lost his job and get treatment after a heart attack. Soon he began bringing his neighbors to meet with the health workers too.

鈥淛akara helped me when I really needed help, so that鈥檚 why I trust Jakara for other community members,鈥� he said through a translator. 鈥淲hen I was drowning, they threw me a lifesaver.鈥�

The community health workers also began organizing health resource fairs for Punjabi residents and provided translation and information at events held by other organizations. The fairs bring in medical providers to offer free health screenings and local agencies such as the Department of Social Services and Area Agency on Aging to sign people up for Medi-Cal, Medicare, and other social safety-net programs. Community health workers also regularly go door-to-door in Punjabi neighborhoods to offer their services and tell people about upcoming events.

鈥淲e鈥檝e learned we have to go to people. We have to go to where they鈥檙e at; they鈥檙e not going to come to us,鈥� Mandip Kaur said. 鈥淲hen someone has so much on their brain and so much on their shoulders, it鈥檚 a task鈥� to seek out health resources.

On one recent visit to an apartment complex, Mandip Kaur helped a man understand a letter he鈥檇 received in English from the local Medi-Cal plan, CalViva Health, telling him he鈥檇 lost his benefits. She promised to help him resolve the matter the next day. She also pulled out her phone to show a visiting neighbor how to get to a local food bank and information about an upcoming job fair.

Also at the apartment complex, resident Manjit Kaur, 58, expressed thanks for the Jakara Movement community health worker who helped her quickly get an appointment with a Punjabi-speaking dentist after she became bedridden with tooth pain. Her friend, Kulwant Kaur, 62, said the Jakara Movement had helped her obtain rental and food assistance after her husband died. 

鈥淭hank God they鈥檙e there to help us,鈥� said Kulwant Kaur, whose adult children live in India. 鈥淭hey鈥檙e like our daughters and kids that we have here.鈥�

A Trip to the Optometrist

One regular event the Jakara Movement organizes is a monthly farmers market at a park on the west side of Fresno, where many community members live. Named after a Sikh human rights activist, Jaswant Singh Khalra Park is within walking distance of several housing complexes where many Punjabi residents live. On a given day you might see older men in turbans playing cards, women in saris pushing strollers, and young people playing cricket on the baseball field. The farmers market caters to the community with fresh produce such as mustard plant that can be used to cook traditional dishes like saag. And it provides another opportunity for Jakara Movement workers to connect with community members.

It was at the May farmers market that Jakara Movement community health worker Harjit Kaur spotted Nirmal Singh and Daljit Kaur, who live nearby. She鈥檇 met them at one of the Jakara Movement鈥檚 health fairs earlier in the year, where they鈥檇 mentioned their need for eye exams. There was no optometrist at that health fair. But Harjit Kaur had just heard about a free, mobile vision clinic run by a nonprofit organization in another part of town. Would Nirmal Singh and Daljit Kaur like to go?

Harjit Kaur spent the rest of the day with the couple. Because Nirmal Singh鈥檚 vision made him hesitant to drive and his wife doesn鈥檛 drive at all, Harjit Kaur drove them to the clinic herself, stopping by their apartment to pick up an old pair of Nirmal Singh鈥檚 glasses. She interpreted during the eye exams, which took several hours. The next day, she picked up the couple鈥檚 new prescription glasses and dropped them off at their apartment.

This ability to spend time with the people they鈥檙e serving and understand their needs is what makes community health workers so valuable, said Andrea Mackey, who oversees a community health worker coalition on behalf of the California Pan-Ethnic Health Network. These workers are from the communities they work with. They understand the lives, culture, and language of the people they help and are passionate about the work they do. This allows them to build trust and serve as a bridge between underserved communities and mainstream systems. In fact, community health workers have been shown to , lower health care costs, and reduce health disparities.

鈥淚t鈥檚 an anti-racist strategy, shifting power to the people who experience health care inequities,鈥� Mackey said, although she acknowledged 鈥渂igger structural problems鈥� such as the cost and complexity of America鈥檚 health care system, particularly for people of color who don鈥檛 speak English or are low income.

For Harjit Kaur and other Jakara Movement health workers, helping the community is just as much a calling as it is a job. Selfless service to others, or seva, is a key tenet of Sikhism. The workers do everything they can to assist people, whether that鈥檚 driving them to doctor鈥檚 appointments, accompanying them to the DMV, or translating during a medical visit. Harjit Kaur and Mandip Kaur said they also donate a portion of each paycheck back to the Jakara Movement, their temple, or people in need. 

鈥淲hen I came to Jakara, I found the purpose of my life,鈥� said Harjit Kaur, who became a community health worker after raising three children and leaving a difficult marriage. 鈥淗elping my own community, speaking my own language, and getting paid鈥攊t鈥檚 a blessing.鈥�

The work is also an extension of what some of the workers were already doing for family members and neighbors. Mandip Kaur, for example, grew up translating and making phone calls for her parents, who arrived in the U.S. when she was 3.  Community Health Worker Gurpreet Singh, 25, who lives in nearby Madera, is the go-to translator for his parents and their Punjabi-speaking friends. He鈥檚 seen firsthand how language, information, and transportation barriers prevent people from getting help.

鈥淚 think the role that community health workers play is super important,鈥� he said. 鈥淪ometimes it鈥檚 as important as a doctor. A doctor鈥檚 visit is scheduled for 15 minutes, 30 minutes max. But what we do as community health workers is really listen to the community members, take our time, and build that trust.鈥�

California has around 8,700 community health workers, according to the , although Mackey says that鈥檚 likely an undercount because not all people doing the work classify themselves as such. Like the Jakara Movement, many organizations pay for these workers with grants and donations. But in July 2022, California began paying for community health worker services for Medi-Cal enrollees. The rollout of this benefit has been bumpy, due to and . A pay increase next year for workers providing services to Medi-Cal enrollees is expected to provide some relief.

The state needs more community health worker programs like the Jakara Movement鈥檚, particularly for Punjabi residents, said Simranjit Mann, a graduate student in public health from California State University, Fresno. Mann did her on barriers Punjabi residents in Fresno face in accessing diabetes care. She said she was surprised at the scarcity of research on the health care needs of Punjabi people living in the U.S. and culturally effective interventions. Expanding these types of programs will require more research to understand what works best so it can be replicated, she added.

The Jakara Movement is currently preparing to do its own research on how to best help Punjabi families achieve and maintain good health, Naindeep Singh said. Later this year the organization plans to launch a three-year program that will serve 500 Punjabi-speaking families in Fresno and hire additional community health workers to visit them regularly, conduct basic health screenings, and survey them about their health needs and challenges. The goal is to help these families access the resources they need and, by analyzing the results, build a better understanding of how to best serve them.

鈥淎t the most basic level, I hope the families have an immediate benefit in terms of what they thought was possible,鈥� Naindeep Singh said. 鈥淎nd I hope there鈥檚 a larger story to tell about how we should be doing health in Fresno and California 鈥� reaching out to people where they live, appreciating and recognizing them and their autonomy to make choices, and just helping them reach the goals they set.鈥�

Meanwhile, Nirmal Singh and Daljit Kaur are already benefiting from the existing community health worker program. They both have up-to-date prescription glasses. Nirmal Singh can see clearly at work, and he鈥檚 no longer afraid to drive. Daljit Kaur isn鈥檛 falling as much as she used to. But the optometrist said she will need cataract surgery to fully restore her eyesight. Mandip Kaur and Harjit are looking into low-cost options for her.

鈥淚鈥檓 very, very thankful,鈥� Nirmal Singh said.

This story was produced in collaboration with the California Health Report. Aallyah Wright with Capital B, Emily Schabacker with Cardinal News, Claudia Rivera Cotto with Enlace Latino NC, and Jenny Stratton with CatchLight contributed to this report. This story is part of a collaborative reporting effort led by the Institute for Nonprofit News鈥� Rural News Network. Support from the Walton Family Foundation made the project possible.