Abstract
Excerpted From: Alicia Turlington, Jonathan Young and Dina Shek, Quantifying “Community Power” and “Racial Justice” in the Medical-Legal Partnership Literature, 51 Journal of Law, Medicine & Ethics 748 (Winter 2023) (43 Footnotes) (Full Document Requested)
The Medical-Legal Partnership (MLP) model, established in 1993, is a highly successful national movement with its core being the partnering of medical providers and legal professionals to address health inequities. MLP practice generally encompasses three core activities: (1) direct legal services co-located and integrated into the healthcare setting; (2) interprofessional training and education; and (3) policy and systemic advocacy work. Essentially, a health care provider identifies a health-harming legal need, connects a patient to a MLP lawyer, and a lawyer provides their expertise to meet this legal need. And together--doctors, lawyers, and patients (and patient communities)--collaborate to address “big picture” policy solutions. Health-harming legal needs are complex social problems that go beyond the expertise of the traditional health care team. The expertise of a lawyer can, for example, resolve individual patient problems ranging from family law and domestic violence needs to housing and income challenges, while also tackling issues of discrimination in the workplace, school, or other systems.
The tremendous impact of the MLP movement is now widely known, and MLPs are cited in key policy papers in the traditional medical and legal fields. The American Academy of Pediatrics, for example, promotes the MLP model for combating such societal and health harming ills as childhood poverty, and much of the foundational health justice scholarship has grown out of the work of many MLP scholars and practitioners.
One of the primary activities of the MLP model is to impact policy beyond the individual patient/client case, reaching broader community impact and heading “upstream” to address the root causes of the social determinants of health (SDOH). This upstream policy change requires clarity about our shared goals and values. And how we get there matters. For example, without careful thought towards building trusting relationships and supporting community power with the people we serve, MLPs run the risk of creating policy without the meaningful inclusion of patient/client communities.
As we begin our examination of how the MLP field practices justice, two approaches inform our focus on centering and building community power. From the medical field, the “medical home” concept is often used to place the patient at the center of all that is done. While the medical home was traditionally conceived as a centralized place of care, it has evolved to signify “partnership between health care professionals and families.” In the legal field, rebellious lawyering (also, community lawyering) describes an inclusive approach where “lawyers must know how to work with (not only on behalf of),” “to collaborate with,” and to be “educated by” the people they purport to serve. The authors have previously explored the concept of a “medical-legal home” to connect these two approaches in the MLP framework.
These concepts center the patient/client at the hub and characterize the direct legal services that MLPs engage in. The MLP model also encourages partnerships to go further, “leveraging their considerable knowledge and expertise to advance local and state policies that lead to safer and healthier environments.” Significantly, just as the patient/client must be central in the medical-legal home, so too must the patient/client community be central in any policy and advocacy work that affects them. The rebellious lawyering approach encourages communities to be active agents in policy change and equal problem solvers to the legal and medical professionals with whom they are allied. Thus, words like “community power” and “power building” are appropriate terms to describe the systemic impact work and policy advocacy at the community level when MLPs partner with communities.
Fostering and wielding effective community power demands a reckoning with the history and impact of racism in America. Thus, terms and concepts related to power cannot be discussed without consideration of racial justice, race, and ethnicity, as it is widely known that racism (interpersonal, institutional, and structural) negatively impacts health. This discussion, however, has been woefully absent previously in MLP literature and the movement has faced internal critiques in this regard. Indeed, as argued by one of our authors, “the critical element missing from the MLP approach is an examination of race and racism as a key structural system in the U.S. that impacts nearly every aspect of our work to improve health and wellness.”
Further, in a white paper from the Brookings Institution, Dayna Bowen Matthew admonishes MLPs for not doing more to address racism's role in the SDOH including in racial segregation in housing and racial inequities in education:
Given the strong legal prohibitions against racial and ethnic discrimination, and the evidence that prohibited discrimination is a primary driver of residential segregation and its health-harming effects, MLP activity on these legal issues could be more robust. MLPs are active, however, protecting against non-racial forms of discrimination. ...
While some MLPs like those at Whitman-Walker Health in Washington, D.C. and the Crossroads Medical Clinic in Mississippi focus on removing discriminatory barriers that impact HIV/AIDS patients and the LGBTQ community, currently, no MLP in the nation focuses on reducing health disparities by broadly addressing racial and ethnic discrimination in education or any other social determinant of health.
This is a striking criticism of an otherwise acclaimed model for reducing SDOH. This 2017 critique, however, may not reflect the current state of affairs. In her 2022 article, “Towards Racial Justice: The Role of Medical-Legal Partnerships,” Medha Makhlouf contends that “participants in academic MLPs have sought to align the MLP model with the health justice framework, which emphasizes the importance of racial injustice. However, this conception is still emerging and may not be widely known or accepted among researchers or MLP practitioners on the ground.” She also argues that MLP's “original framing through a singular poverty lens” is now a barrier for MLP to overcome in reframing itself as a racial justice intervention.
While the hypothesis that the MLP model is lacking in its examination of race and racism is held by some MLP academics, it has not been empirically shown that the published MLP research (as a studiable proxy for the model, movement, and practice) is lacking in this regard. As MLP is inherently multidisciplinary and its participants span from public health and medicine through law, discussion of this issue must engage all perspectives, from the qualitative arguments to the quantitative. Using bibliometric methods to study the MLP health literature, we quantified the observance of terms that illuminate concepts of “community power” and “power building,” “power and engagement” as well as “racial justice.” We hypothesized that these terms would be scant, but that perhaps due to a national time of racial reckoning, they may have increased.
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We believe that the MLP field must continue to evolve to promote community power and to center racial justice in order to have the upstream impact in SDOH and policy that MLPs prioritize. Understanding where we are in the process, as demonstrated by our analysis of the MLP literature, is the first step in that evolution.
At the Medical-Legal Partnership for Children in Hawai'i (MLPC), we have previously written about our own evolving praxis, first recognizing the need to create a medical-legal home, to centering a racial justice framework, to now prioritizing our role in building community power. Our next step towards strengthening community relationships and elevating community power is to invite our clients and community partners to dream and to build a shared vision of what kind of world they want. Inviting people to dream and listening to their dreams is a step towards seeing people for all their humanity. When we believe that people don't dream--and don't carry dreams for their children--we are taking a dangerous step towards dehumanizing them. Perhaps having people simply share dreams together is a tool that more MLPs can use to build community power as Lopez urges us to do, by working with, not only on behalf of, the people we serve. And as practice is reflected in the scholarship, perhaps future bibliometric search terms will include “dreaming” and “envisioning” as essential measures of MLP practice.
Indeed, several critical MLPC Hawai'i collaborations grew out of moments when government and agency leaders made statements that our Micronesian client communities “have no dreams” and are “not responsive” to outreach. In one instance, our MLPC health center partner, K kua Kalihi Valley Comprehensive Family Services, hosted a gathering of Micronesian community leaders to meet with local law enforcement to identify collaborative solutions to juvenile justice concerns. At one point, a family court judge declared, “These parents have no dreams for their kids!” and in that moment, any hope of understanding and collaboration was gone.
Years later, in the earliest months of the COVID-19 global pandemic, a government health official claimed Micronesian pastors and leaders were “not responsive” to outreach efforts. This claim was also repeated by the Honolulu Police Department following a police shooting and killing of a 16-year-old Micronesian boy. Contrary and in response to these perceptions, Micronesian leaders formed a Micronesian Ministers & Leaders Uut (Chuukese word for a gathering house) that has met every Tuesday night by Zoom videoconferencing since mid-2020 through today to address critical community issues including pandemic-related health education, community resource sharing, civil rights, and community justice matters. MLPC Hawai'i staff was first invited to the Uut to discuss and address employment rights during the pandemic, and we became regular participants and co-organizers of the weekly gathering. The Uut is a place to share resources, organize community education, and also to dream and envision together. And from these opportunities to dream, we build a shared vision for our collective future, enlivening and guiding our MLP work.
While the MLP movement evolves to center community power--as evidenced by the shifts in scholarship in this study documenting MLP practice--we can look back 35 years to the words of Lucie White in her article titled, “Mobilization on the Margins of the Lawsuit: Making Space for Clients to Speak.” She urges us to consider that “A single moment of mobilization has some value, even when it makes no concrete contribution to the litigation effort.” She continues:
For the clients, it creates a history, a context, for further action in the future. And for the lawyers, if they listen carefully, these moments can make them aware of their clients' worlds, of the power and visions that their clients can bring to a shared project for change.
The MLP network is positioned to lead and transform traditional medical and legal service models to embrace these values and approaches, and to work alongside our patient/client communities, to dream and envision together, and to build our collective power.
Alicia Turlington, M.D., is an Assistant Professor at the John A. Burns School of Medicine (University of Hawai'i at Mnoa) and serves as the Medical Director for the Medical-Legal Partnership for Children in Hawai'i at the K kua Kalihi Valley Comprehensive Family Services.
Jonathan Young, M.S., M.L.I.S., Ph.D., is a Science and Technology Reference Librarian at the University of Hawai'i at Mnoa, Hamilton Library.
Dina Shek, M.A., J.D., is a Faculty Specialist at the William S. Richardson School of Law (University of Hawai'i at Mnoa) and serves as the Legal Director of the Medical-Legal Partnership for Children in Hawai'i.
