advocacy in medicine: a new way forward ellen lawton, jd lauren smith, md, mph department of...
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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
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