Justice As Medicine: Legal Representation As A Public Health Strategy

From San Francisco to Miami to Baltimore, mayoral elections this fall will shape the future of American cities for decades to come. While many of these elections are focused on housing, homelessness, and public health, an overlooked approach that sits at the intersection of all three is access to legal representation. Many have argued that legal representation is a civil right; it may also be a fundamental public health necessity.

Consider Michelle’s story. Michelle is a 52-year-old grandmother living in public housing with her two young granddaughters. Their unit was riddled with black mold and sewage backups so severe that they had to use buckets of water to bathe. Despite repeated pleas to her landlord, no repairs were made. As their living conditions worsened, so did their health. Michelle made several trips to the emergency room—first for respiratory issues due to mold exposure and later for gastrointestinal problems exacerbated by the unsanitary conditions. Michelle’s health, along with her granddaughters’, kept deteriorating as the underlying issue was not addressed. Worse yet, due to a rent miscalculation, her landlord threatened to evict her and her family. However, once she got legal services, the issues were fixed within weeks, and the threat of eviction was removed.

Michelle’s story isn’t an isolated case. Legal issues frequently snowball into health crises, especially in housing. As an ER doctor in San Francisco, I have treated patients who have lost their homes because they can't afford legal counsel to contest unsafe living conditions, address domestic violence, or prevent wage theft. In California, for example, it’s estimated that 92% of low-income families with legal issues are unable to access legal help. And once someone becomes homeless, their health deteriorates rapidly.

Legal barriers often accelerate, or even trigger, the journey from housing instability to homelessness. Without access to legal representation, people are evicted, lose access to critical services, or face unsafe conditions without recourse. For two decades, I’ve witnessed the devastating toll of untreated mental health issues, substance use, and chronic illnesses in homeless populations, as well as the impact it has on our emergency departments and health care system. Research shows that homelessness exacerbates both mental and physical health issues. A study from San Francisco's Open Door Legal found that legal representation prevented 46% of clients at risk of homelessness from losing their homes. The cost? About $3,100 per person. Compare that to the $83,000 Santa Clara County spends annually on each homeless individual, with 61% of that cost going to healthcare services.

It’s no secret that healthcare and housing are inextricably linked. And while there’s growing recognition of this reality through, for example, new Medicaid programs that provide housing support and non-medical services like air purifiers or financial coaching, there’s an essential missing piece. People living in precarious housing need legal advocates to protect their rights.

We could prevent countless public health emergencies by providing legal aid before people reach the point of crisis. Legal representation can keep people in stable housing, prevent evictions, and address unsafe living conditions before they lead to ER visits. The downstream effects of legal intervention are profound: fewer health crises, fewer ER visits, and fewer people forced onto the streets.

Universal legal representation may be both a moral imperative and a pragmatic one. It’s an essential part of the strategy for the rising healthcare costs associated with homelessness. If we can reduce homelessness cost-effectively, our healthcare system will be far less burdened.

As we enter an election cycle where public health and housing are central concerns, policymakers may benefit from understanding that legal representation can be a health intervention. We need a system where access to justice is prioritized as highly as access to healthcare because in many cases, they are one and the same. It’s time we treat access to legal representation as an essential part of our public health infrastructure.