By Liz Tobin-Tyler and Joel Teitelbaum
To us, health justice means change.
Changes to norms and attitudes, to systems and environments, to law and policy, to resource and opportunity distribution. Not cosmetic or peripheral change, but wide-scale, systemic change. For health justice to be realized — for all people to reach their full health potential — laws and policies must be geared toward restructuring the systems, practices, and norms that have heretofore advantaged some groups over others, and thus given them greater opportunity for good health, economic and social prosperity, and greater longevity.
We recognize that this kind of change is profoundly challenging, both biologically and structurally. Biologically, because humans are programmed to do what’s comfortable, and what’s comfortable is what’s already known. Structurally, because of the nation’s unique political, social, and cultural attributes. Some of these attributes include a strong sense of individualism, and thus an entrenched unwillingness to prioritize community benefit over individual choice; limited governmental power; capitalism; unprecedented wealth with massive inequality; resistance to growing racial and ethnic diversity; over-spending on the downstream consequences of the failure to invest in upstream wellness; and a willingness to enact and maintain policies and practices that privilege some lives over others.
For these reasons, we are not naïve about the prospects for major change in a relatively short period of time, but neither are we cowed by the challenge. We embrace the opportunity to get uncomfortable, to challenge the racist, gender-based, and ableist norms and attitudes in all forms that harm health and well-being, to raise awareness of the inert systems that perpetuate health injustice, and to promote innovative and progressive law and policy change.
One of the ways that we apply our approach to health justice is our work to develop and advance medical-legal partnerships (MLPs), as both an expert consultant (Liz) to and Co-Director (Joel) of the National Center for Medical-Legal Partnership.
MLPs represent a collaboration between health care organizations (hospitals, health centers, managed care organizations, etc.) and public interest law organizations (typically a civil legal aid agency, but oftentimes a law school clinic) to address health-harming social needs that have civil law remedies. The specific legal issues addressed by MLPs commonly mirror those of traditional civil legal aid practice: housing instability (e.g., evictions, habitability, wrongful utility shutoffs), public benefit needs (e.g., access to public health insurance programs and Social Security income), food insecurity, special education plans, immigration status determinations, family matters (e.g., custody/visitation rights, domestic violence), and more. But MLP practice is more than the resolution of specific health-harming social and legal needs — it is about institutional change at both health and legal organizations, and it is about upstream law and policy change using the lessons of MLP practice.
MLPs provide an excellent platform from which to explore and demonstrate how laws and policies affect individuals, communities, and populations. By tracing the patterns of injustice experienced by individual patients and communities, MLPs support public health and legal researchers to identify law and policy gaps and the under-enforcement of protective laws.
MLPs also engage medical, public health, and legal partners as advocates for changes that address health injustices. In the MLP world, this is referred to as the “patient-to-policy” approach. Advocacy for health justice in the health care system, in communities, and in state and federal government is only effective if policy and systems changes make demonstrable differences in the lives of people who experience daily injustices. In MLP advocacy, patients’ and clients’ stories drive policy change efforts, but MLPs must also empower communities in their own fight for justice.
We also use an MLP lens to write about health justice by framing MLP within the context of civil rights, by encouraging health care professionals to engage in upstream structural change in partnership with legal professionals, and by connecting patients and clients’ lived experiences of injustice to influence public health advocacy.
Our national work in building and growing the MLP movement has contributed to our teaching strategies and content. This work is grounded in the belief that catalyzing the next generation of legal, health care, public health, and public policy professionals to work together for health justice is, itself, an important step toward structural change.
As the MLP movement gained momentum in the early 2000s, Liz co-edited Poverty, Health and Law: Readings and Cases for Medical-Legal Partnership (2011) to provide teaching materials designed for interprofessional health justice education. Teaching health justice through the MLP approach not only helps students conceptualize the role of law and policy in disparate health outcomes, it reframes understandings of their future profession and practice toward interprofessional advocacy to promote structural change.
As legal scholars and instructors who work in medical, public health, and legal education, we teach students to think critically about how laws and policies as written (laws on the books) and implemented and enforced (laws on the streets) serve as root causes of poor health and health injustice. This involves digging deeply into the ways in which laws both set the stage for poor health in marginalized communities and the ways in which systems, driven by the biases and indifference of those who govern and work in them, affect the lives of people in these communities. In 2019, we co-wrote a textbook primer titled Essentials of Health Justice. In 2022 — with new co-author Ruqaiijah Yearby — we will release an expanded edition designed for an interdisciplinary audience of law, medical, public health, public policy, and other health professions students to explore the connections among laws, policy, and structural health inequities.
The expanded book will build on our work with MLP and the original primer by interrogating the nuanced ways in which laws and policies funnel down to the daily health injustices and indignities experienced by people every day in marginalized communities across the U.S. We frame health justice in the context of critical theories, social movements, health-harming legal doctrines and human rights principles; we explore health injustice through the lens of structural inequity, including the history of legalized discrimination, socioeconomic and place-based inequities, and the role of the carceral state; we describe the health injustices experienced by historically excluded populations (Asian, Black, Indigenous, Latinos and other People of Color, immigrants, women, LGBTQ+ people and people with disabilities); and we contemplate change: a far more vibrant health justice agenda for the future.
Liz Tobin-Tyler, JD, MA is Associate Professor of Family Medicine and Medical Science at the Alpert Medical School and of Health Services, Policy and Practice at the Brown University School of Public Health.
Joel Teitelbaum, JD, LLM is Professor of Health Policy and Director of the Hirsh Health Law and Policy Program at the Milken Institute School of Public Health, and Co-Principal Investigator of the National Center for Medical-Legal Partnership.