Numerous studies have documented that racism is a social determinant of health (SDoH) that negatively impacts Black, Indigenous, and people of color (BIPOC). As such, racism is one of “the conditions in which people are born, grow, live, work, and age” that are “mostly responsible for unfair and avoidable differences in health statuses.”
The U.S. health care system was not designed to respond to SDoH, much less to address racial health disparities. In fact, U.S. health care institutions have racist legacies that continue to influence the way they operate today. When health care providers fail to confront racism within and outside their walls, they perpetuate the racial health disparities that have plagued our nation since before its founding.
Medical-Legal Partnership (MLP) is a model of collaboration and joint advocacy between lawyers and health care providers who seek to improve social conditions that affect health and well-being. MLPs aim to address SDoH on three levels: direct representation in civil legal matters, institutional change, and systemic advocacy. They typically employ legal interventions to ensure that people’s basic needs are met, such as nutritious food, health care, income, safe and stable housing, and uninterrupted energy and water utilities. Improving access to such resources is an important way of engaging with the work of health equity.
While some MLPs incorporate a racial justice lens in their work, many do not. MLPs are generally more oriented toward addressing the effects of racism as a SDoH, rather than as the cause of poor health. But considering the cross-cutting nature of racism as a SDoH, MLPs can and should address it directly. As Director of the MLP Clinic at Penn State Dickinson Law, whose faculty has resolved to incorporate discussions of racism and inequality in the curriculum, I have begun researching Critical Race Theory (CRT) as a framework to understand how MLPs can build on their core activities to further address racism as a SDoH and make explicit the connections between racism and poor health. This post describes how MLPs can address racism as a SDoH in at least four ways that align with the goals of CRT.
Education about Inequitable Power Formations
CRT seeks to draw attention to the inequitable power formations that cause racial health disparities. MLP providers seek to educate health care providers about how they can address patients’ SDoH and inspire them to become better advocates. In these presentations, MLP trainers should describe how racist policies contribute to the disproportionate poverty and need for legal assistance in BIPOC communities. Trainers should identify existing laws and policies that adversely affect BIPOC and educate providers about their privileged role in anti-racist advocacy efforts.
Such efforts should begin early in the course of medical training. Law faculty who direct MLP Clinics should partner with medical faculty to design interprofessional exercises that will encourage students to examine the racialized power dynamics inherent in their roles as lawyers or health care providers and inspire them to reflect on their own positions in institutions that are stratified by race. Early exposure to these issues will increase students’ ability to identify and address systemic causes of racial health disparities in the future.
Sensitization to the Health Impacts of Intersectional Discrimination
MLPs serve patient-clients who are affected by intersectional systemic bias. Because MLPs provide holistic services to address a variety of socio-legal and health needs, health care and legal service providers in MLPs have access to a more detailed social history than most medical providers working alone. Rich social histories help to humanize patient-clients, enabling providers to look beyond racist diagnostic heuristics they learned in training and that are often reinforced in practice.
MLP participants with a “willingness to listen for the race stories” from patient-clients are presented with case studies of how racism intersects with other systems of oppression—such as classism, sexism, heterosexism, ageism, and ableism—to impact health. They may move beyond addressing patient-clients’ individual legal needs by identifying patterns of health-harming legal issues impacting BIPOC, revealing the systemic causes of racial health disparities. This perspective should inspire MLP participants to invest advocacy resources toward building power in BIPOC communities.
Uncovering the Inadequacy of Law on the Books
When health-promoting laws are underenforced, their ability to reduce racial health disparities is weakened. Students in the Medical-Legal Partnership Clinic at Penn State Dickinson Law work to ensure that laws governing public benefits are properly enforced. This helps to prevent and ameliorate health problems among our clients, who are typically members of one or more groups that face significant health disparities, such as low-income people of color without U.S. citizenship.
For example, Clinic students recently obtained publicly funded health insurance for a client with kidney failure who had been erroneously denied such coverage based on her immigration status. The intersection of public benefits and immigration law is complex, which means that eligibility determinations for noncitizens are prone to error. Each client presents a vivid example of the inadequacy of laws enacted to protect and support low-income communities when such laws are underenforced.
Incorporating Multidisciplinary Approaches to Understanding Health Disparities
MLPs are designed to bring together the skillsets of multiple disciplines—including law, medicine, nursing, social work, and public health—to improve health outcomes. Each field has its own literature on and educational methods involving CRT. MLP participants who are familiar with this literature and responsible for training future members of their fields can provide students with a broader perspective on the causes of and solutions to racial health disparities by integrating insights from multiple disciplines.
The National Center for Medical-Legal Partnership, an organization at the center of the MLP movement in the United States, has recently highlighted the need to dismantle racist systems as part of its strategy to reduce racial health disparities. As more MLPs begin exploring how to address racism as a SDoH, they should consider incorporating CRT as a framework. MLPs, particularly those located in academic institutions, can and should aim to (1) educate lawyers and health care providers about inequitable power formations that cause racial health disparities, (2) sensitize participants to the influence of intersectional discrimination through direct advocacy with and for BIPOC, (3) document the inadequacy of underenforced law on the books, and (4) include multidisciplinary approaches to understanding racial health disparities.
Medha D. Makhlouf is an Assistant Professor and Director of the Medical-Legal Partnership Clinic at Penn State Dickinson Law. She has a joint appointment in the Department of Public Health Sciences at Penn State College of Medicine.