Advocacy in Medicine: A New Way Forward

1. 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

2. 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

3. 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.”

4. 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.

5. 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 Unhealthy Trade-offs: Food vs. Basic Necessities

6. 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

7. 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 Avoid harmful exposures in the home?

8. The Hegemony of Low Expectations

9. Competing priorities drain parent’s worry budgets

11. 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

12. Factors Influencing Child and Family Health Hunger and Nutrition Housing, Utilities and Homelessness Employment and Income Domestic or Community Violence Health Insurance Child and Family Immigrant Status Education Childcare and Parenting Support Disability

13. Struggling to Navigate the “Safety Net” Food Stamps, WIC, Pantries BHA, other LHA’s, DTA, ABCD DET, DTA, DOR Police, Courts, DSS DMA Child and Family Head Start, EI, BPS, other LEA’s USCIS SSA, DTA, DPH, DMH, DMR DTA, DSS, ABCD

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

15. The Role of Medical Legal Partnerships • 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.

16. Current MLPC Programs Chicago, IL Detroit, MI Ann Arbor, MI Cleveland, OH Portland, ME Manchester, NH Boston, MA Chelsea, MA Worcester, MA Providence, RI Hartford, CT New York, NY (3) Albany, NY Syracuse, NY Buffalo, NY Rochester, NY Baltimore, MD Washington, DC Charlottesville, VA Ashville, NC Durham, NC Nashville, TN Atlanta, GA Jacksonville, FL Billings, MT Minneapolis, MN (2) Sioux City, IO Iowa City, IO St. Louis, MO Carbondale, IL Oakland, CA Palo Alto, CA Los Angeles, CA Orange, CA San Diego Tucson, AZ • 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)

18. Disrupting the Link Between Social Factors & Health Outcomes: DO BOTH!