What Does Health Justice Mean to You?

I am excited to share a recent Q&A on my work and thoughts on health justice. This piece (original post here) is part of a new series on the Network for Public Health Law Blog highlighting the Network's ongoing efforts to advance health justice through public health law and policy resources, technical- and capacity-building assistance, and training.

More importantly, we want to hear from you. Please share your thoughts on health justice, let us know how we can support your efforts in this area, and join us at PHLC18: "Health Justice: Empowering Public Health and Advancing Health Equity," October 4-6, 2018 in Phoenix, AZ. You can also reach out to me directly at [email protected].

Homelessness is a Health Justice Issue: Q&A with Madeline Morcelle

Q: What does health justice mean to you?

A: The U.S. spends significantly more on medical care than any other nation, but morbidity and mortality rates for perinatal conditions, complications from pregnancy and childbirth, gun violence and numerous other conditions are among the worst in the developed world. This disconnect stems from our societal failure to correct underlying social, political and cultural issues that shape health inequities. One-fifth of Americans live in environments that harm their health—communities where an absence of public spaces and sidewalks discourage physical activity; where interpersonal violence is alarmingly common, causing a broad range of physical and behavioral population health harms; or where unaffordable housing leaves little for food, health care and other basic needs. Average life expectancy can vary by as much as 25 years among children born in neighborhoods just miles apart. In 2014, 53% of Americans who died from HIV lived in the South. In this respect, geography is destiny.

The U.S. health disadvantage weighs heaviest upon people of color and poor, politically oppressed, and socially isolated populations. Black mothers die in childbirth at 2 to 3 times the rate of White mothers. LGBT youth are at increased risk of cardiovascular diseases, cancer, obesity and suicide. The rate of death from drug overdose is as much as 16 to 24 times higher among people experiencing homelessness than in the general population.

I view health justice as a direct outgrowth of the civil rights movement. The Medical Committee for Human Rights, National Medical Association, and individuals including Dr. H. Jack Geiger and Dr. John W. Hatch combatted Jim Crow care, unsafe housing conditions, food insecurity, and poverty through legal challenges, legislative advocacy, and community action. Their countless legacies include the passage of Medicare and Medicaid in 1965, creation of more than 1,400 community health centers nationally, and integration of social and legal services into health care delivery. Yet, as current health inequities illustrate, their work remains unfinished and fiercely urgent.

Most immediately, health justice demands that we empower vulnerable individuals and communities to fully participate in crafting and implementing responses to population health problems. It also necessitates continued efforts to infuse population health into health system reforms. Ultimately, it requires collective responsibility for the constellation of social, economic, and political formations and power imbalances that shape health inequities.

Q: How do laws impact public health?

A: Law is not always a positive determinant of public health. In fact, health inequities are deeply embedded in laws and policies that reinforce barriers to care and social participation. Criminal laws and prosecutions targeting individuals based on HIV status, substance use disorder, or homelessness further stigmatize already marginalized populations while creating new barriers to health. Preemptive legislation stifles and snuffs out hard-fought grassroots battles for state and local public health law innovations. Yet, law is also one of the most powerful health promotion instruments at our disposal, capable of ensuring access to lifesaving health care and social services; encouraging healthier behaviors; and liberating populations from repetitive cycles of poverty, discrimination, and political oppression that drive social injustices in health.

Q: What are some of the key issues or initiatives you’ve been working on at the Network, and how can law and policy make an impact in those areas?

A: I have the privilege of leading our Western Region efforts on health justice for people experiencing homelessness. Stable, affordable, and adequate housing is instrumental to health. Individuals experiencing homelessness face tremendous barriers to care and disproportionate rates of emergency department utilization as well as morbidity and mortality from acute, chronic and behavioral health conditions. In the midst of a worsening affordable housing crisis, total homelessness increased for the first time in seven years in 2017, reflecting a nine percent increase in the number of people experiencing homelessness without shelter. Early reports from the 2018 Point in Time count estimate a 25% increase from last year in the number of people sleeping on the streets here in Maricopa County, Arizona, where our Western Region Office is based.

Instead of providing pathways out of homelessness through housing and health-related supports, municipalities increasingly turn to legal measures which effectively criminalize survival by prohibiting life-sustaining activities such as sleeping in public. Criminalization creates new barriers to housing, employment, benefits and other health-related basic needs. Additionally, it burns through limited public resources that could be more efficiently invested in solutions to homelessness. Between 2010 and 2014, the enforcement of ordinances criminalizing homelessness cost six Colorado cities an estimated $5 million. Our emerging efforts address the proliferation of these measures, their population health consequences, and constitutional challenges. We are also working to evaluate, elevate, and build capacity for legal and policy alternatives that appropriately address homelessness as a public health and civil rights issue. 

I also lead the Network’s Western Region Medical-Legal Partnership (MLP) efforts. MLP is a model that integrates legal and policy advocacy into the health care continuum. MLPs provide direct legal services to low-income individuals to address serious health-related social needs. For example, a MLP may help an individual access public benefits or work to enforce legal protections from housing discrimination and unhealthy housing. These efforts give MLPs remarkable insight into population-level legal and policy barriers to health, as well as the societal costs of health-related harms. Consequently, they are well positioned to advocate and organize for policy reforms that improve population health, such as expanded utility shut-off protections. Thanks to the vision and leadership of Colleen Healy Boufides, Senior Attorney in our Mid-States Region Office, the Network is collaborating with the National Center for Medical-Legal Partnership and regional MLPs partners to advance public health policy reforms targeting population health needs.

Q: What made you decide to go into public health?

A: I entered law school dedicated to social justice lawyering. My decision to focus on public health resulted from a combination of poverty and health law coursework, summer work focused on health reform and HIV law and policy, and environmental osmosis. After three years surrounded by pervasive and systemic health inequities in the rural South, I graduated with a passionate commitment to advancing health justice for vulnerable populations. Ultimately, I hoped to focus my public health practice on building capacity and amplifying change in under-resourced areas through legal and policy technical assistance—the central task of my work at the Network for Public Health Law.

Q: Has your thinking about the role of law and policy in public health changed at all since you’ve been working at the Network? 

A: My work at the Network has enabled me to broaden the scope of my practice beyond core health care and public health laws to address how constitutional, civil rights and criminal laws impact population health.

Q: What is the most important thing that we as a nation could be doing with regard to public health policy?

A: Although the U.S. made great strides toward increasing individual access to health care services through the Patient Protection and Affordable Care Act, significant health inequities and systemic inefficiencies persist. A Health in All Policies approach could improve population health outcomes at a lower cost by facilitating accountability for the root causes of poor health across sectors.

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