Medical-legal partnerships: transforming health care

by Barry Zuckerman; Megan Sandel; Ellen Lawton; Samantha Morton Doctors, especially those who care for patients on low incomes, are frustrated that their patients’ health is adversely affected by social determinants. For those patients with an acute or chronic illness, social determinants undercut the effectiveness of the burgeoning number of drugs and other treatments. Although this problem is usually considered a public-health issue, experience in the USA and abroad suggests a new way to transform the health-care system to address these social determinants: train lawyers to work as part of the health-care team to enforce the laws and regulations that are in place to protect health. Many governmental programmes and laws, including programmes to supplement nutrition, housing subsidies, utility assistance, income support for the elderly and disabled individuals, regular and special education services, and health insurance, were created to ensure that basic needs are met. Unfortunately, safety nets are now so complex and unwieldy that many parts of the net are rendered inaccessible, and the disregard of laws and regulations, such as those intended to protect against unhealthy environments, can result in adverse effects on health. Individuals and families on low incomes cannot on their own successfully challenge the unlawful actions of a landlord, a governmental agency, or a school system, and therefore many unlawful-and unhealthy-situations persist. As a result, physicians are now looking to lawyers as colleagues to “treat” the social determinants of health, and medical-legal partnership is emerging as a key strategy to combat health disparities. For example, in cases where a landlord ignores the pleas of a parent, nurse, or doctor to fix the leaky pipe that is causing mould that triggers a child’s asthma, a lawyer has the skills to contact the landlord and cite the housing and sanitary codes that are being violated. Wrongful denial of benefits can be overturned. Typically, this type of legal intervention gets results for patients without the intensive and expensive litigation often associated with legal services. Thus medical-legal partnerships have introduced the concept of preventive law, to help vulnerable individuals and families avoid legal crises that have health effects. Science Photo Library People on low incomes in the USA typically have two or three unmet legal needs, which may be acute or chronic. Virtually all legal needs (ranging from housing issues to domestic violence) are directly or proximally connected to health status. he medical-legal partnership model was developed at Boston Medical Center in 1993. A National Center for Medical-Legal Partnership was created in 2006, and there are now over 120 health clinics and hospitals in the USA that partner with legal-aid agencies, pro-bono lawyers, and law schools to offer legal assistance in the health-care setting to advocate for patients whose basic needs are not being met. Each community across the USA has some form of legal aid agency and with training, their lawyers can be co-located and work efficiently in the medical setting. Lawyers’ expertise in navigating decision-making systems, asserting different types of legal authority, and advocating persuasively and effectively, complements physicians’ clinical skills, to provide an important synergy to address social determinants of health. Medical-legal partnership has several advantages. For many vulnerable patients, accessing stand-alone legal services offices can be a challenge, from a lack of transportation and time to patients not recognising their problems as having legal solutions. Even more importantly, this strategy increases the likelihood that patients will receive the help they need before a deprivation of basic needs leads to a crisis. As with preventive medicine, new generations of lawyers are practising a form of preventive law which allows for the identification of legal needs before they turn into legal-and health-emergencies, such as child abuse, homelessness, failure to thrive, and severe asthma episodes. A 2007 American Bar Association Resolution supports this model as an important mechanism for early identification and remediation of legal violations. Finally, inviting lawyers to join in the delivery of health care expands the lens through which physicians view their patients, and the universe of their patients’ needs-thus encouraging a culture of advocacy within the health-care setting. Medical-legal partnership is a flexible model that can be effectively implemented in countries other than the USA if safety-net and related laws are inadequately enforced. While the UN Convention on the Rights of the Child provides an important framework for both health-care professionals and lawyers, an active strategy to enforce existing laws-especially those that ensure access to basic needs, such as food, housing, safety, health care, and education-is essential.5 In 2006, the Open Society Institute’s Law and Health Initiative began piloting several projects to integrate legal services in health-care settings in under-resourced areas.6 More recently, the Society published a report, Tipping the balance: why legal services are essential to health for drug users in Ukraine, that describes how legal advocacy can address the health needs of drug addicts. In the USA, the future of medical-legal partnerships will involve broad expansion to multiple high-risk populations (the model originated in paediatrics), such as those who are elderly, disabled, or affected by chronic disease. The reorientation of health-care systems to early identification of social determinants and legal aid to prevention of legal emergencies that lead to adverse health is opening a new frontier to address the non-biological factors that profoundly influence health. Medical-legal partnerships have the potential to catalyse permanent institutional change and a reallocation of resources and priorities in both legal and health communities, in the USA and internationally. This work was done with support from the Kellogg Foundation, the Robert Wood Johnson Foundation, the Public Welfare Foundation, and Atlantic Philanthropies. We thank Melissa Brennan for her help in preparing this manuscript. We declare that we have no conflict of interest.