By Genya Shimkin, Public Health Practitioner and Educator.
A study published in December 2024 found that a right-to-counsel in New York City led to improved birth outcomes for families facing eviction.[1] To those of us working in public health, this makes perfect sense; the relationship between stable housing and improved health is well-documented, and the threat of eviction can cause tremendous stress especially during pregnancy. Outside of our field however, this link may not be clear. Studies like these highlight the potential for legal system interventions to improve public health.
In public health, we talk a lot about structural and social determinants of health (SSDOH). These are the non-medical/non-biological factors that influence a person’s health: systems, environments, and exposures such as racism, sexism, socio-economic status, education level, housing, neighborhood, and immigration status.[2] Indeed, we recognize that these factors account for up to 80% of an individual’s health profile. We live in a country where your zip code is a better predictor of your life expectancy than your genetics. That’s because of SSDOH. And in public health, we understand that addressing these foundational determinants of health is key to health equity and justice.
Dr. Camara Jones, one of the nation’s leading experts on racism as a public health crisis, beautifully explains how racism permeates our systems: “The most profound impacts of racism are because structural racism has been institutionalized in our laws, customs and background norms. It does not require an identifiable perpetrator. And it most often manifests as inaction in the face of need.”[3] Racism is a structural determinant of health because of how it functions to “structure opportunity and assign value” as Dr. Jones says; race itself is a social determinant of health because race itself is socially constructed and is a downstream consequence of racism.
This means that racist policies can trickle down to create health disparities. Policies like redlining, which kept people of color out of certain neighborhoods, meant that people of color were then relegated to communities with less green space, fewer food options, higher rates of poverty, and schools with lower funding levels (because of lower property values and therefore lower tax revenues). This leads to higher rates of chronic disease, more difficulty accessing care, and higher morbidity and mortality.[4] Though redlining is no longer formal policy, its legacy is omnipresent in American cities.
We are living in a moment where every aspect of health and healthcare has become political; where policies dictate who can access care, where they can access care, and which care clinicians can legally provide. We are also seeing mass censoring of key public health data, as the Federal Government removes data sets from its websites[5] and makes unilateral decisions about who can collect data and what data they can collect.[6] The downstream effects of this politicization are devastating our most marginalized community members: folks who are poor, people of color, queer and trans folks, people with disabilities, immigrants, and others bear the brunt of these consequences. They face additional barriers to care, to equity, and to justice.
Where SSDOH become barriers to justice, legal interventions can make a difference for people at the margins. When we look at public health interventions, it is helpful to understand levels of impact. The socio-ecological model provides a framework for understanding relationships between individuals, communities, institutions, and society at large[7]:
The outer rings of the model represent “upstream” interventions, which have greater potential for impact, and require significantly more effort and upfront investment. For example, individual clinicians counseling people on safe firearm storage has a much smaller impact on population health than federal policy regulations. The more we move towards the upstream interventions, the more we rely on collaborations with other sectors.
For a person facing eviction, legal counsel is not only essential for keeping their home, their possessions, their family together; it is also essential to preserving health. Housing is a major determinant of health,[8] and the loss of housing is catastrophic to a person’s mental, physical, and emotional health. While we in public health know that reality, we are not always well-positioned to intervene and make a difference. We need legal experts to use their skills to step in and advocate for those facing eviction. And we need our legal partners as collaborators in policy advocacy to address underlying inequities in housing.
One model that brings together legal and public health interventions is Medical-Legal Partnerships, which embed attorneys into healthcare clinics to assist clients with complex medical, social, and legal needs.[9] By placing legal experts next to healthcare providers, attorneys become part of a healthcare team, addressing legal issues alongside clinicians working on social and healthcare needs. When the barrier to health justice is a legal one, lawyers are close at hand to help patients navigate the complex processes, which in turn improves their health.
Our systems are not set up to encourage collaboration; they are designed to maintain the status quo, which consolidates power among a small group while keeping so many poor and sick and disenfranchised. Keeping us siloed works to limit our power, potential, and progress. That we struggle to connect the dots between legal systems and public health systems is by design. Achieving health justice in this country will require a massive cultural shift, a coordinated effort, and a sustained commitment. We cannot achieve these goals without de-siloing our professions and collaborating across fields.
[1] Leifheit KM, Chen KL, Anderson NW, et al. Tenant Right-to-Counsel and Adverse Birth Outcomes in New York, New York. JAMA Pediatr. 2024;178(12):1337-1344. doi:10.1001/jamapediatrics.2024.4699
[2] Healthy People 2030, U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion. Retrieved [date graphic was accessed], from https://odphp.health.gov/healthypeople/objectives-and-data/social-determinants-health
[3] Oregon State University. “Racism: What it is, how it affects us and why it’s everyone’s job to do something about it: Bray lecturer Camara Jones addresses racism as a public health crisis.” https://synergies.oregonstate.edu/2020/racism-what-it-is-how-it-affects-us-and-why-its-everyones-job-to-do-something-about-it/
[4] Kraus, N. T., Connor, S., Shoda, K., Moore, S. E., & Irani, E. Historic Redlining and Health Outcomes: A Systematic Review. Public Health Nursing, 2024;41(2): 287-296. https://doi.org/10.1111/phn.13276
[5] Cox C, Rae M, Kates J, Wager E, Ortalilza J, Dawson L. “A Look at Federal Health Data Taken Offline.” Kaiser Family Foundation. Published Feb 2, 2025. https://www.kff.org/policy-watch/a-look-at-federal-health-data-taken-offline/
[6] Yourish K, Daniel A, Datar S, White I, Gamio L. “These Words are Disappearing in the New Trump Administration.” The New York Times. Published March 7, 2025. https://www.nytimes.com/interactive/2025/03/07/us/trump-federal-agencies-websites-words-dei.html
[7] Fry JP, Stodden B, Brace AM, Laestadius L. “A Tale of Two Urgent Food System Challenges: Comparative Analysis of Approaches to Reduce High-Meat Diets and Wasted Food as Covered in U.S. Newspapers.” Sustainability. 2022:14(19). DOI: 10.3390/su141912083
[8] “Housing And Health: An Overview Of The Literature, ” Health Affairs Health Policy Brief, June 7, 2018 .DOI: 10.1377/hpb20180313.396577