Advocacy in Medicine: A New Way Forward

Ellen Lawton, JD

Lauren Smith, MD, MPH

Department of Pediatrics

Boston Medical Center

Boston University School of Medicine

Just What the Doctor Ordered ….

Eat healthy, well-balanced diet Lower in fat Lower in cholesterol Lower in sodium

Exercise regularly Avoid unhealthy exposures Avoid unhealthy behaviors

Smoking Excessive alcohol Street drug

Nutritional Challenges – The Real Cost of Healthy Diet

2005 BMC study in Dorchester, Mattapan, South End Healthier diet $148 more than maximum Food

Stamp benefit Healthier foods often missing from smaller stores “Low income families in Boston relying on Food

Stamps will have significant difficulty purchasing a diet that follows recent nutrition guidelines.”

Availability of a healthy diet? Lack of full-sized grocery stores Limited selection in smaller stores

Fruit & vegetable intake increased 32% for each additional supermarket. (Morland K, AJPH 2003)

Availability of unhealthy options Fast food restaurant density related to income and %

black residents of neighborhood. (Block JP, Am J Prev Med 2004)

Minority and low income neighborhoods are much more likely to have fast food restaurants and fewer supermarkets.

Unhealthy Trade-offs: Food vs. Basic Necessities

• Housing• Heat• Medical expenses• Transportation

• “Rent or eat”– Children eligible for

but not receiving housing subsidies are 8 times more likely to have stunted growth

• “Heat or eat”– Low-income

children show poor growth in the winter

Avoid unhealthy behaviors?

Targeted marketing to minority & low income communities

More tobacco billboards Disproportionately concentrated alcohol ads Increased number of liquor stores and underage

sales Specific targeting of alcohol & tobacco ads using

cultural references, ethnic-specific characters

Avoid harmful exposures in the home?

Rodent and cockroach infestation

Water leaks and resultant mold

Peeling paint and lead paint Exposed wires and

uncovered radiators Insufficient heat or running

water Overcrowding

Increased asthma Increased lead poisoning Injuries

Radiator burns Window falls Fires from improper wiring,

lack of smoke detectors, use of space heaters

Increased infectious diseases

The Hegemony of Low Expectations

If your child had asthma symptoms 2 days/wk, how would you rate his/her control?

0

5

10

15

20

25

30

35

Ex VeryGood

Good Fair Poor VeryPoor

Pe

rce

nt

Competing priorities drain parent’s worry budgets

Percent of parents worrying about the following issues "all", "most" or "some of the time"

0

10

20

30

40

50

60

70

Housing Safety Relationships Income Own/other'shealth

Child'sasthma

Per

cen

t

The Challenge Minority & low income patients are

more likely to have difficulty obtaining factors that protect health and are more exposed to factors that harm health

These patients carry a disproportionate burden of disease BEFORE ever entering health system

Child and Family

Housing, Utilities and Homelessness

Domestic or Community

Violence

Hunger and Nutrition

Employment and Income

Health Insurance

ImmigrantStatus

Childcare and Parenting Support

Disability

Education

Factors Influencing Child and Family Health

Child and Family

BHA, other LHA’s, DTA,

ABCD

Police, Courts,

DSS

Food Stamps, WIC, Pantries

DET, DTA, DOR

DMA

USCIS

DTA, DSS, ABCD

SSA, DTA, DPH, DMH,

DMR

Head Start, EI, BPS, other

LEA’s

Struggling to Navigate the “Safety Net”

The Scope of Unmet Legal Needs

• Poor families have significant unmet legal needs

• Most legal needs are going unaddressed– Study identified large gaps

between legal needs & receipt of help for those needs

• Legal help for poor families is limited – Publicly funded legal aid turns

away up to 60% of cases due to lack of resources

State YearAve. # Legal

Needs in Prior Year

OR 2000 3.2

VT 2001 1.1

WA 2003 2.9

MA 2003 2.4

TN 2004 3.3

IL 2005 1.7

Source: Legal Services Corporation, Documenting the Justice Gap in America, 2005

Medical-Legal Partnerships foster collaboration between health care & legal service providers to ensure that children’s basic needs are met.

3 basic activities of Medical Legal Partnerships:

Education and training of front-line health care providers to identify legal needs and take appropriate action.

Direct service to low income families through legal information, advice, or representation.

Systemic advocacy for policies that promote child health.

The Role of Medical Legal Partnerships

Oakland, CAPalo Alto, CALos Angeles, CAOrange, CASan DiegoTucson, AZ

Chicago, ILDetroit, MIAnn Arbor, MICleveland, OH

• 39 programs at 73 clinical sites as of November 2006• 13 additional programs in development (expected start in 2007)• Programs currently in 21 states and D.C. (5 additional states represented among the 13 developing sites)

Portland, MEManchester, NHBoston, MAChelsea, MAWorcester, MAProvidence, RIHartford, CTNew York, NY (3)Albany, NYSyracuse, NYBuffalo, NYRochester, NYBaltimore, MDWashington, DCCharlottesville, VAAshville, NCDurham, NCNashville, TNAtlanta, GAJacksonville, FL

Billings, MTMinneapolis, MN (2)Sioux City, IOIowa City, IOSt. Louis, MOCarbondale, IL

Current MLPC Programs

Disrupting the Link Between Social Factors & Health Outcomes:

DO BOTH!

Development of illness Severity of illness

Individual

Biologic predisposition

to illness

Increased Risk Poverty Poor housing quality Environmental

exposures Poor nutrition/ Food

insecurity Safety

Decreased Access Language barriers Geographical

barriers Inadequate health

insurance Lack of benefits

Health Care

Policy & Advocacy