We're Asking Health Care to Fix Something It Didn't Break

Co-authored by Megan Sandel, MD, MPH; Associate Professor of Pediatrics at Boston University Schools of Medicine and Public Health; Medical Director of National Center for Medical-Legal Partnership; @megansandel

We're starting to understand that poverty causes illness, not just for individuals, but for whole communities. Yet we talk about the effects of substandard housing, poor nutrition, and violence in a vacuum separate from the laws and policies that create and perpetuate these problems in the first place. And then we ask health care to clean up the mess.

Health care has long been in the business of treating the negative health effects of bad social policy. When there isn't enough safe affordable housing, when sanitary codes are unenforced and when cuts are made to housing voucher programs, doctors treat people for the injuries and asthma that ensue. When people live in food deserts without access to healthy food, or their SNAP applications are wrongfully denied, nurses help patients manage the low blood sugar episodes for diabetics who are hungry. And health care spends a lot of money doing it.

Now more than ever, with the prevention mandates of health reform, we are asking health care to be in the business of preventing illness. That's a tall order when so much of what makes people sick are underenforced laws and policies, underfunded public programs and ill-conceived public policies way outside the scope of what health care professionals are trained to do. Indeed research shows that only about fifteen percent of preventable illness can be improved with access to better medical care alone.

Health care providers should screen patients regularly for "social vital signs" -- problems with housing, hunger and domestic violence -- all of which are equal predictors of poor health as any vital sign taken for blood pressure or heartbeat. But we cannot ask nurses and doctors to write prescriptions for healthy housing or food when those "pharmacies" are empty.

To better treat and prevent expensive and prevalent health problems, doctors and nurses need two things: a specialist to address the problems they uncover when they screen patients for social barriers to health, and help enforcing laws and changing policies that create these problems in the first place. Who can help? Civil legal aid attorneys. More than 230 hospitals and health centers across the country have made lawyers part of their health care teams through medical-legal partnerships (MLP).

If a family lives in unsafe apartment, the simple answer is to suggest they move. But more often than not that isn't an option. The news is full of reports of decreases in affordable housing and increases in multiple families living in a single apartment. Even if the family could find a safe, affordable alternative, we'd only leave the unhealthy apartment to make the next family sick. Recently in Cincinnati, a group of doctors sent three patients to see an MLP attorney, all of whom had been threatened with eviction for asking their landlords to improve substandard housing conditions. The lawyers worked to help the families, and in the process discovered that all of them lived in buildings owned by the same landlord. Working together, the health care and legal teams were able to get 19 buildings rehabbed and under new management. The finished buildings didn't just help those three families; they stocked the healthy housing pharmacy for more people in the community, and kept people healthy who might have otherwise been next in line at the hospital.

If we are going to ask health care to do more to prevent illness then we have to be honest about where poor health originates, and we have to give doctors and nurses tools and partners to treat the problems they identify. Most important, we have to consider the health of individuals and our communities in every conversation and every policy about housing, education and food. We can't just expect health care to clean up the aftermath of whatever we decide.