This post is part of a symposium from speakers and participants of Northeastern University School of Law’s annual health law conference, Diseases of Despair: The Role of Policy and Law, organized by the Center for Health Policy and Law.
All the posts in the series are available here.
By Tamar Ezer
As we grapple with today’s social ills and Diseases of Despair such as the opioid crisis, violence and suicide, medical-legal partnerships (MLPs), can potentially provide a powerful healing combination.
MLPs, which integrate legal services into health care, have several important strengths.
They embrace a holistic approach to health, addressing not just biological factors, but also social determinants, such as access to housing or freedom from violence. They bring access to justice to communities. People need not go out to seek legal support, but can find services at a one-stop shop for multiple, intersecting needs. MLPs help address legal issues early, preventing problems and intervening before there is an eviction or utilities are shut off.
While more research is needed on the effectiveness of MLPs, there are some promising initial results. For example, “Access to Justice: Evaluating Law, Health, and Human Rights Programmes in Kenya,” discusses how MLPs in Kenya integrated legal support into HIV and post-rape care and have impacted patients, providers, and service delivery itself.
Through rights literacy training, patients increased practical knowledge of how to claim rights, which had a multiplier effect, as patients shared this knowledge with their communities. The integration of legal support further led to an attitude shift, and patients were more empowered to speak out against violations, form support groups, and engage in local advocacy.
As one client said, “We have been trained on our rights, and we can now confidently talk about our rights before the chief and village elders.”
Additionally, the MLPs resolved issues of discrimination, gender based violence, land and property ownership, as well as established access to housing and child maintenance—components of economic and physical security that are critical social determinants of health.
Providers became more adept at identifying human rights violations and legal issues. They provided patients with information on their rights, referred patients to legal aid, and even assisted with basic legal documentation. With increased referrals, the MLPs also saw an increase in access, as well as satisfaction with services. Patients were more comfortable in their interactions with health care providers, and providers were better equipped and more confident in responding to patients experiencing violations.
A study of MLPs focused on serving the needs of veterans in Connecticut and New York went further in assessing the impact of the MLPs on health. According to that study, within the first three months of participating, veterans showed significant improvements in mental health, including decreased anxiety, stress, hostility, paranoia, and psychosis. At 12 months, veterans continued to demonstrate these improvements and showed an increase in income and days housed as their legal issues were resolved.
More MLP services further correlated with decreased spending on abuse substances and better mental health—regardless of whether or not legal goals were achieved. Veterans who did achieve their legal goals showed greater improvements in housing, income, and their sense of citizenship and community integration.
While MLPs often focus on the power of an alliance of two influential professions with diverse skills, there is also an essential role for partnership with communities. The Veterans MLP in West Haven is fundamentally community-centered, providing legal services alongside health services, job training, and various peer activities. It further employs veterans, who make up half the staff, and clients participate in the organization’s governance.
This community orientation is reflecting in the MLP’s physical spaced, as noted by a law student volunteer who described a welcoming space with big windows that encouraged people to dream of possibilities, as well as private rooms for client meetings “without trappings or status,” and “spatial arrangements” that “echo” the “fluid path of referrals.”
He wrote, “The hallways are narrow and packed. When rounding a corner, you unexpectedly bump into familiar veterans and diverse colleagues—lawyers, nurses, social workers, doctors, staff. There are no formal gatekeepers to the law, unlike at courthouses or law firms. A veteran with a medical appointment next door might simply drop by to see a lawyer.”
Community engagement is likewise central to MLPs in Kenya and Uganda. This includes a focus on rights literacy and community-based paralegals. UGANET’s (Uganda Network on Law, Ethics and HIV/AIDS) integration of legal support in the context of HIV is one example.
Community paralegals are particularly well-placed to deliver rights education and provide “legal first aid,” responding quickly to violations, addressing multiple needs that are not just legal, and connecting their peers to further support as needed.
As one sex worker said, “We speak the same language.”
In the United States, we have seen a growing role for community health workers. An MLP in New Haven, which serves patients recently released from prison, employs community health workers with a personal history of incarceration to help patients navigate medical and social services.
A randomized controlled trial showed that support from a community health worker could lead to a 15 percent reduction in proportion of patients with any Emergency Department visits and 51 percent drop in frequency of Emergency Department visits among other patients. This echoes similar studies. For instance, one study in Atlantic City showed that employing health coaches from patient communities who spoke the patients’ language and had personal experience with chronic illness led a 40 percent drop in emergency room visits and hospital admissions and 50-point average drop in cholesterol levels among patients with high cholesterol.
MLPs and partnership with communities can thus be important ingredients in tackling diseases of despair—both through individual services, as well as laying the groundwork for systemic advocacy.
Tamar Ezer is the Associate Director, Lecturer in Law, and Practitioner-in-Residence with the Human Rights Clinic at the University of Miami School of Law. Please see https://www.law.miami.edu/faculty/tamar-ezer.
This symposium is published in partnership with: