It’s Friday morning, and there’s a hubbub on the adolescent wing at Boston Medical Center (BMC), where three of Sharon Morell’s four children are getting a check-up. Dr. Megan Sandel is speaking with the two younger kids, Elisa and Nelissa, 8 and 9, about their asthma.
When Elisa takes a deep breath, Sandel notices the girl is wheezing a bit. She prescribes a drug for immediate relief in addition to the one Elisa has been taking to control the problem. Then the doctor turns to Sharon and asks her about a different subject: her housing. The family’s living conditions might not be affecting Sharon’s kids’ health, but Sandel knows that poor housing and asthma are often linked.
Sandel has known the Morells for several years. When they met, the family was homeless and Sandel had a job going to the city’s shelters to run clinics. She continued to see the family after she began working at the hospital, monitoring both their medical and housing needs. She eventually played a pivotal role in helping the Morells find a permanent home.
It isn’t just that Sandel takes a particular interest in her patients’ lives. She and other BMC pediatricians are part of the Medical Legal Partnership for Children (MLPC), which gives them legal remedies to help their patients. When Sandel sees that kids have health problems that stem from their housing, she calls on lawyers who are on the hospital’s staff. They make it possible for her to not only treat people’s health in a clinical setting, but also to be their advocate in the community.
Doctors’ Secret Medicine
In 1993, doctors at BMC resolved to do something about the fact that many of their young patients’ health conditions never improved, and sometimes worsened, even after they were on medication. Often their parents were one step away from eviction, or their heat was about to be cut off, or the state had denied them food stamps. Families would tell their doctors about these problems, but the doctors didn’t know what to do.
It was not unusual for the problems to become emergencies by the time doctors were aware of them. “You don’t get to see cases before they turn into a crisis, because people aren’t motivated to seek your services until they have a crisis on their hands. They don’t think of it,” says lawyer Ellen Lawton, MLPC’s executive director. “We prioritize utility cases, because for families they’re really the harbinger of doom. That’s the first thing people stop paying when they can’t make ends meet.”
When the hospital stationed lawyers on its adolescent wing, it made it much easier for families to get legal help, since they would be able to see their doctor and a lawyer at the same time. They wouldn’t have to go across town to the Legal Aid office. At the same time, the lawyers tended to know about resources the doctors didn’t, like financial help for people who are not citizens and for others not poor enough to qualify for public assistance.
Over time, MLPC started to extend its services to neighborhood health centers, which low-income people tend to use even if they don’t go to the hospital. The program began offering legal clinics at the health centers to educate people about their rights. Meanwhile, the lawyers trained the doctors to take action themselves, by writing letters to bad landlords to advise them of their patients’ concerns. If a landlord was unresponsive, the doctors had legal help at their disposal. “I’ve been kind of spoiled; I don’t know how to practice without having the help of a lawyer on my team,” says Sandel.
She first turned to BMC’s lawyers after the Open Society Institute gave her a fellowship in 2002 to work on social justice issues from a medical perspective. The grant called for her to work with the Boston Housing Authority (BHA) and its tenants to make it easier for people with health problems to transfer to new units. “We had seen a bunch of cases of kids who were extremely sick because of their housing conditions,” she says. “The process by which you could transfer from one unit to another was very slow, and no one understood how the process worked.”
Sandel became an advocate for the tenants. Her lawyer colleagues taught her how to write letters that described tenants’ medical problems in layman’s terms and cited the specific housing codes that were violated. She also worked with housing authority staff to teach them how to recognize when tenants were really sick.
After awhile, Sandel realized that just transferring tenants from one unit to another wasn’t enough. In one case, she wrote a letter on behalf of a family with a two-year-old that lived on the seventh floor of a building with a broken elevator. To make matters worse, someone was always pulling the fire alarm. The mother complained that frequent trips down the stairs and out into the cold were making her child’s asthma worse. She was transferred to a first floor apartment in a different development, where she found new problems: a dumpster laden with trash right out front, and cockroaches in the apartment.
“The kid got sicker,” says Sandel. “I ended up much more interested in BHA’s maintenance problems. The family often didn’t really want a transfer – they just wanted the condition fixed.”
A Systemic Approach
While Sandel’s initial approach was to work with individual tenants as she met them at the hospital, her fellowship work also brought her into contact with the Committee for Boston Public Housing (CBPH), a tenant advocacy group. The committee had been working on the asthma issue since 1996, including taking part in research projects with several Boston universities to identify what causes the illness.
What they found was that even if the BHA did general maintenance, it wasn’t enough to keep out pests like mice and fleas that trigger asthma. The committee wanted BHA to do substantive repairs, such as patching up holes in the walls, to keep the problems from recurring. They were especially concerned about Whittier, one of the older housing developments in the Roxbury neighborhood. In 2005, a local environmental justice group, Alternatives for Community and Environment, was organizing Whittier tenants on health issues and invited Boston city councilors to come see the conditions in the hallways and apartments.
Once the councilors saw how the tenants were living, they held hearings on the issue. Among those who testified was Sandel. “It’s hard when a doctor is looking you in the face and saying, ‘this is a health issue,’” says Mae Bradley, CBPH’s executive director. “If a tenant says it, you might say, ‘you’re not a doctor, you don’t know what you’re talking about, go clean your unit.’” The council ordered the city’s inspectional services department to pay a visit to all the units at Whittier that had problems, and BHA soon made the repairs. “I think they would not have done so in such a timely manner, had Megan not been at the table,” adds Bradley.
Chuck Turner, who represents Roxbury on the city council, met frequently with Whittier tenants as they organized to demand repairs. He says getting the BHA to fix some of the problems was a big victory, but that much work remains to be done to make Whittier a comfortable place to live. There are some repairs that can’t be made easily without major structural work that would force residents to relocate. For example, the bathrooms are poorly ventilated, and over time steam has damaged the wooden ceilings.
In general, MLPC tries to take a diplomatic approach with BHA. “I have tried to take more of a carrot than a stick approach with them,” says Sandel. “I say, ‘I’m sympathetic with how few resources you have, so let’s work together on this.’ As opposed to, ‘we’re going to call the newspaper and show how ridiculous these conditions are.’”
With private landlords, the doctors and lawyers are less willing to accommodate. Sandel recalls a case in which a landlord refused to provide pest control. City inspectors visited multiple times and fined the landlord, but the problem continued. Finally MLPC sued under consumer protection laws and got a settlement for the tenant’s family, which used the money to pay for first and last month’s rent and move into a new apartment.
Information = Power
Though the city’s inspectional services unit has been cooperative with MLPC and nonprofit groups like CBPH, it wasn’t always so. “For a long time it was seen as a worthless resource – families would never get any kind of results from an inspection,” says Jean Zotter, director of the Boston Urban Asthma Coalition and a former attorney at the Family Advocacy Project, now MLPC. “They have a long history of failing residents and being on the side of homeowners.”
That changed, she says, after her group and others pushed the city to institute a Web-based database to keep better track of troubled housing units. The concept, dubbed Breathe Easy, resulted from community groups’ frustration at the city’s lack of follow-up after inspections. MLPC offered funding for technical assistance to create the online database. Now Sandel and other doctors can track cases through the Web site, and the system will automatically e-mail doctors when the city updates a housing unit’s status. Since doctors have access to more information, they are less likely to have to turn to lawyers to get results.
Some 50 percent of the referrals to Breathe Easy come from public housing developments. That fact helped the city, together with CBPH, to win a $2 million grant from the W.K. Kellogg Foundation last April to rid 15 housing developments of pests and their root causes. The grant will pay for CBPH to hire and train at least 10 tenants as advocates in their neighborhoods, and will also pay for more BHA staff to address health issues. The tenant advocates’ job will be to educate their neighbors on common sense ways to keep their units clean and pest-free. For instance, they will show residents how to clear space in their apartments when an exterminator comes. Meanwhile, BHA staff will have an incentive to practice efficient pest control through building repairs such as properly sealing doorways or patching holes in the floors.
While she is encouraged by the increased cooperation with city agencies, Bradley says she can also see the potential for working with MLPC in other public housing developments to accomplish what they did at Whittier.
“If the problem is totally out of control and becomes a code compliance issue, we can still meet with the resident association and see if they want to organize on a community-wide basis, like Whittier did, get the city council involved and get BMC involved,” she says.
Spreading the Word
Besides being a pediatrician, Sandel is also national director of education and training for MLPC. She and Lawton are helping hospitals in cities across the country to develop collaborations between doctors and lawyers based on the Boston model. At least 33 hospitals and clinics have started programs so far.
In each case the model is slightly different. In most, lawyers aren’t actually on a hospital’s staff. Instead, hospitals and community health centers collaborate with Legal Aid programs. In Boston, MLPC lawyers often refer cases to Legal Aid, who are the “specialists,” says Lawton. “We’re the primary care providers.” Because many patients won’t go to Legal Aid on their own, the lawyers at the hospital often direct them there after an initial conversation. Whether a hospital provides legal services on-site or refers patients to lawyers in the community, the ultimate intent is the same: to try to solve people’s medical and legal problems at the same time.