The connection between health and social factors — like housing, food security, education, and exposure to violence — is clear.Reference Braveman and Gottlieb1 So, too, are the challenges faced by a health care system that, increasingly, is expected to address these connections, notwithstanding the disconnect between the field's bread-and-butter approach of treating individual symptoms and participating in population-level strategies designed to reduce the myriad structural and social barriers to good health.Reference Berman2 Because many of these barriers can be both rooted in and remedied by civil law, partnerships among health, public health, and legal experts are essential to effectively address upstream causes of poor health.
Law Is a Critical Determinant of Health
Laws constitute the societal building blocks that should enable everyone to lead safe, healthy lives. According to the Centers for Disease Control and Prevention, seven of the ten greatest public health achievements in the United States during the 20th Century — immunizations, motor-vehicle safety, workplace safety, infectious disease control, drinking water fluoridation, tobacco control, and food safety — were grounded in the use of law.3 Furthermore, federal laws and programs such as Medicaid, Medicare, the Public Health Service Act, the Affordable Care Act, the Women, Infants, and Children Supplemental Nutrition Program, and the Ryan White HIV/AIDS program are just a few of the many examples (including numerous state laws) of legal building blocks that, in theory, provide the foundation for a healthy nation.
At the same time, the inequitable design and application of laws and legal policies in sectors as diverse as housing, education, labor, lending, transportation, and criminal justice undermine health. For example, a housing code that goes unenforced in an asthmatic child's apartment often means that the child's health condition worsens, resulting in missed school days, missed work days for her parents, and unnecessary medical bills. On the flip side, the relatively strict enforcement of drug laws against populations of color results in the mass incarceration of African-American males, and associated negative health consequences for incarcerated individuals, their families, and their communities.Reference Bailey4
The unequal application of laws and policies across multiple sectors perverts what should be a more equitable distribution of social benefits, incomes, and punishments, contributing to a raft of health disparities.Reference Tobin-Tyler and Teitelbaum5 Furthermore, an old but massive crack in our legal foundation continues to destabilize the nation's health: the racially discriminatory laws that no longer govern but are nonetheless powerful correlates of health in communities of color. Our nation's history of genocide, enslavement, oppression, and “redlining” institutionalized the economic, educational, and social disadvantages that for people of color remain forceful predictors of health and well-being.Reference Schwarz6
Thus, while factors like substandard housing, employment discrimination, and food insecurity are important determinants of health, these factors should not just be understood as having remedies in law; they must be recognized as often being the result of laws or their unjust application. Health professionals must appreciate how laws and legal policy not only can be used to remediate individual health-harming legal issues, but also can act as inputs to poor health at levels far upstream from individual health conditions. Through permanent and robust medical-legal collaboration scaled to achieve population-level health improvements, the unique expertise and approaches of the health care, public health, and legal professions can promote solutions to the nation's ever-worsening health inequity crisis.
While factors like substandard housing, employment discrimination, and food insecurity are important determinants of health, these factors should not just be understood as having remedies in law; they must be recognized as often being the result of laws or their unjust application. Health professionals must appreciate how laws and legal policy not only can be used to remediate individual health-harming legal issues, but also can act as inputs to poor health at levels far upstream from individual health conditions. Through permanent and robust medical-legal collaboration scaled to achieve population-level health improvements, the unique expertise and approaches of the health care, public health, and legal professions can promote solutions to the nation's ever-worsening health inequity crisis.
Historical Collaboration between the Medical and Legal Professions
There is nothing particularly novel about medical-legal collaboration. While popular understanding of the relationship between the two professions is one of mutual contempt, there is actually an impressive history of effective collaboration when social exigencies push them together.Reference Teitelbaum and Lawton7 For example, lawyers helped doctors create some of the medical profession's earliest standards, while lawyers routinely ask doctors to provide expert testimony in lawsuits.Reference Jacobson8 Physicians and lawyers have also long collaborated to protect human rights, together documenting abuses and developing legal standards to prosecute human rights violators.9
Medical-legal collaboration began to confront racism, poverty, and discrimination at least as early as the Civil Rights Movement, when in the 1960s one of the country's earliest community health centers hired an attorney to “treat” legal problems plaguing patients, including race-based discrimination and poor housing.Reference Lawton10 The HIV/AIDS crisis further solidified the interdependency of clinicians and lawyers in addressing health-related social needs, as ground-breaking organizations like Whitman-Walker Health in Washington, D.C. not only provided health care to those afflicted with the disease, but legal services, too, which addressed issues ranging from estate planning to securing disability benefits.11
Formalizing Collaboration for the Benefit of Patients and Communities: Medical-Legal Partnership
Medical-legal partnerships (MLPs), in which lawyers are integrated into health care settings to serve as patient-facing experts in the battle against health-harming legal issues, are the latest example of collaboration between the professions. With roots in the earlier doctor-lawyer alliances, MLPs have spread consistently since the mid-1990s, with some 350 MLPs now in operation around the country. Although MLPs are comprised of different types of partners and care for a variety of populations, they tend to share eight core components: (1) a formal agreement between a health care organization and a (typically) nonprofit or academic legal services provider; (2) a defined patient population to be served; (3) a strategy to screen patients for social needs; (4) legal staffing; (5) a “lawyer in residence” at the health care setting; (6) training of health care staff to recognize legal needs; (7) information sharing between health and legal partners; and (8) funding expressly devoted to the partnership.Reference Regenstein, Trott, Williamson and Theiss12
According to the Legal Services Corporation, 71 percent of low-income families have at least one unmet legal need.13 Most of these families experience needs in one of three categories, each of which have direct links to health and well-being: housing, public benefits, and educational supports. As an integrated service of a holistic health care team, MLPs can help provide solutions to individual patients' health-harming legal issues at the point of care, both in moments of crisis and as a matter of prevention (e.g., by preventing an unlawful eviction).
While MLP services aim to improve a single patient's health, they also serve to effectuate health equity at the community level. Two examples illustrate this effect. First, at Whitman-Walker Health, lawyers and health care providers teamed up with community allies and patient advocates to challenge the proposed elimination of a health insurance plan in Washington, D.C.'s health insurance marketplace. By showing how crucial this plan is for many HIV-positive individuals who would otherwise not be able to afford their medications, Whitman-Walker ensured its continuation.Reference Marple and Dexter14 Second, when lawyers at the Cincinnati Child Health-Law Partnership repeatedly heard about unsafe housing for pediatric patients — including pest infestation, water damage, and threatened evictions when tenants made complaints — their investigations identified a large cluster of homes owned by the same company. The MLP instigated repairs or nearby relocation, guaranteeing safer housing for an entire community.Reference Beck15
Viewed through a broader lens, MLPs are important partners in upstream efforts to address social determinants of poor health because their frontline perspective provides insight into specific ways in which laws harm or fail particular populations.Reference Tobin-Tyler16 From this unique perspective, MLPs can contribute in distinctive ways to each of the five essential public health law services that public health legal experts have identified as necessary to the effective design, implementation, and spread of public health legal interventions.Reference Burris17 For example, MLPs are well-situated to gather evidence of implementation and enforcement trends that negatively affect their clients; to guide development of improved laws and implementation strategies; and to identify opportunities for enforcing laws through strategic litigation. Applying a public health perspective to MLP work has enormous potential to channel health care, public health, and legal efforts and resources towards the most widespread and problematic of legal barriers to health while simultaneously assuring that legal interventions are evidence-based and tailored effectively to fix well-defined problems.
Conclusion: Applying a Population Health Lens to Promote Health Equity through Law
The legal system effectively serves as the nation's structural engineer, responsible for designing the many systems meant to prevent illness, promote well-being, and alleviate the pressures of poverty, major health events, and environmental hazards. All of these systems contribute to social determinants of health: “the conditions in the environments in which people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks.”18 A vast body of literature describes how these determinants are not equally experienced by all; indeed, disparities exist in health status as well as in health care access, diagnosis, treatment, and outcomes based on race, ethnicity, socioeconomic status, physical and mental disability, age, gender, sexual orientation, and immigration status. These disparities betray our nation's flimsy efforts to strive for health equity — an environment in which every individual has an equal opportunity to achieve and maintain good health — and they existed long before the current political assault on safety net programs, women's health, income equality, and more.
Public health and health care professionals cannot be expected, without help, to understand, fix, and enforce the myriad laws that can both create and remediate harmful conditions. It is past time for health care providers and payers to explore the role that legal services can play in addressing the out-sized influence that social conditions have on health. As the medical-legal partnership approach demonstrates, legal interventions can be integrated directly into the infrastructure of individual and population health to address both systemic and in-the-moment health-harming legal issues, particularly for patients whose life circumstances make it incredibly difficult to achieve a level of health we all have a right to expect.
