Medical-Legal Partnerships and Legal Regimes: A Health Justice Perspective

Abstract

Medical-legal partnerships (MLPs) attempt to integrate the social determinants of health into health care delivery to eliminate health inequities. Yet, MLPs have not fully adapted to identify and address structural racism, one of the root causes of health inequities. This article provides a health justice perspective on the role of MLPs to challenge legal regimes to address structural racism and reimagine systems rooted in joy, safety, and collective liberation.

Medical-legal partnerships (MLPs) continue to demonstrate positive value and impact in addressing social and legal needs intimately connected to health, using interdisciplinary collaborations between the health care and legal fields.¹ Since their inception, MLPs have grown in scope and size dramatically across the nation, with MLPs in at least 450 sites across 49 states and the District of Columbia.² Recently, Congress passed a $2 million MLP grant program through the 2023 appropriations bill,³ which will continue to support the growth and work of MLPs as legal interventions.

In typical MLP models, health care providers and legal professionals work together in clinical settings to integrate social determinants of health (SDOH) into health care delivery in an effort to “reduce poverty-related barriers to health for clients.”⁴ For example, some MLPs have expanded patient access to financial resources.⁵ Poverty is a significant SDOH⁶ and is associated with long-term negative health outcomes for people with low incomes.⁷ However, addressing poverty as a SDOH also requires challenging structural racism. Structural racism, which is the unbalanced social and economic organization of resources and power to advantage white people and disadvantage racial/ethnic minoritized people,⁸ plays an important role in maintaining poverty and health inequities among systemically minoritized communities.⁹

The COVID-19 pandemic put a spotlight on health inequities among systemically minoritized communities. Black, Latinx, and immigrant communities, in particular, were overrepresented as frontline workers, which was associated with higher rates of COVID-19 exposure and death.¹⁰ Hence, these workers sacrificed their health and well-being in order to feed us and care for us, but were not protected.¹¹ The pandemic sparked a racial reckoning leading to the recognition of racism as a public health crisis across federal, state, and local governments.¹² Yet, to eliminate health inequities, experienced by systemically minoritized communities, structural racism must be addressed. MLPs have a role in addressing structural racism. Specifically, MLPs should expand their model and movement to confront structural racism as a root cause of health inequities.¹³ Without identifying and addressing structural racism, MLPs will be limited in their potential to advance sustainable change.

In this article, I highlight the role of MLPs in challenging legal regimes to address structural racism and assisting in the creation of systems rooted in joy, safety, and collective liberation. Section I briefly summarizes the evolution of MLPs as poverty-focused legal interventions, as well as the failure of MLPs in addressing structural racism as a root cause of health inequities. Section II explains unmet health-harming legal needs as a product of legal regimes, that is, how health-harming legal needs arise largely as a result of keeping systemically minoritized communities away from state and legal power. In particular, I offer a case study of agricultural workers, who are among the most exploited groups in the United States and are routinely excluded from legal protections due to structural racism. Without agricultural workers, the U.S. food production system would not function. Focusing on agricultural workers, I highlight how the current MLP model does not guarantee support and protection to populations who are kept away from state and legal power because of structural racism. Finally, Section III provides insights on how MLPs can shift their model to challenge structural racism and legal regimes, build people power, and reconstruct systems with the leadership of those systemically minoritized—all of which are principles required for achieving health justice.

In this article, I highlight the role of MLPs in challenging legal regimes to address structural racism and assisting in the creation of systems rooted in joy, safety, and collective liberation.

I. Evolution of Medical-Legal Partnerships

The MLP model was originally developed as a poverty-focused legal intervention to address the poverty-related barriers to health for people with low incomes.¹⁴ In 1993, legal services lawyers and pediatricians at Boston Medical Center collaborated together to identify and address health issues that required legal advocacy and representation, such as applying for food stamps and health insurance, helping pay utility bills, and/or holding landlords accountable for poor housing conditions.¹⁵ Accordingly, most MLPs operate to address “health-harming legal and social challenges”¹⁶ within the following areas that intersect with poverty law, referred to as I-HELP: “income and insurance, housing and utilities, education and employment, legal status, and personal and family stability.”¹⁷

Law professor Medha Makhlouf importantly notes that even though “Black, Indigenous, and Latinx people are disproportionately affected by the poverty-related issues that MLPs address,”¹⁸ only 18 out of 241 MLP websites make clear an intention to serve Black, Indigenous, Latinx, or people of color.¹⁹ While the poverty-focused MLP model has achieved some success in positively impacting patient health and well-being,²⁰ such a singular approach is ineffective in creating sustainable change. This is because a monolithic poverty-focused orientation in this way fails to unsettle the legal regimes that sustain health inequities for systemically minoritized communities.²¹ In their current model, MLPs tend to address the “effects” of structural racism only, and consequently, miss a key opportunity to understand and address the significant connections between poverty, structural racism, and health inequities.²²

Medical, public health, and legal research has shown that structural racism is one of the fundamental drivers and root causes of health inequities in access to health care and health status.²³ As defined by public health and legal scholar Ruqaiijah Yearby, “[s]tructural racism is the way our systems (health care, education, employment, housing, and public health) are structured to advantage the majority and disadvantage racial and ethnic minorities. More specifically, it produces differential conditions between white populations and racial and ethnic minorities leading to racial health disparities.”²⁴ Structural racism includes both race-based and race-neutral actions.

Structural racism and resulting health inequities are maintained by “the way laws are written or enforced.”²⁵ Law — “including political processes, statutes, regulations, policies, guidance, advisory opinions, cases, and budgetary decisions, as well as the process of enforcing or failure to enforce the law”²⁶ — itself can be a tool of oppression, excluding minoritized groups from state power, that is, from protections ascribed and granted through law.²⁷ Accordingly, to meaningfully address structural racism as a root cause, MLPs need to not only move past race-neutral language and strategies,²⁸ but also engage in a deeper discussion on how power is maintained through laws and how to shift power towards systemically minoritized communities. The workings of structural racism are particularly evident in the U.S. food production system — a system built upon the foundations of racial capitalism, “operating to produce wealth for a small group, at the expense of public health, the environment, and rural communities.”²⁹

II. Health-Harming Legal Needs and Legal Regimes: A Case Study of Agricultural Workers in the United States

Agricultural workers, who are expected to compromise their safety on a regular basis to keep the U.S. food system functioning, are kept away from state and legal power due to structural racism. The legacies of slavery, Jim Crow, and New Deal laws have played a foundational role in the systemic devaluation of agricultural and domestic work.³⁰ Although slavery legally ended in 1863, federal laws and programs, including Jim Crow laws, ensured that Black people were concentrated in particular occupations in the South, namely agricultural or domestic work.³¹ Many states passed “Black Code” laws that restricted Black people from working in any other industry except agricultural or domestic work.³² States simultaneously prevented Black workers from migrating to northern states for safety and employment opportunities.³³ With such state-sponsored restrictions and exclusion, Black workers became overrepresented and concentrated in the domestic and agricultural industry.³⁴ Over the years, however, “the continued devaluation of domestic and agricultural vocations and the accompanying search for lower-wage laborers of color soon led to a high concentration of Asian American and Latinx workers in domestic and agricultural occupations,”³⁵ many of whom have precarious legal status.³⁶ As of 2022, 70 percent of agricultural workers are foreign born,³⁷ with the majority (78 percent) as Hispanic/Latinx.³⁸

Agricultural workers continue to face socio-political-legal challenges that are intimately connected to their health.³⁹ The agricultural industry, which is majority immigrant, has one of the highest rates of occupational injury in comparison to all industries in the United States.⁴⁰ Due to structural racism that excludes most immigrant agricultural workers from legal protections — such as, immigration status, employment protections, workplace accommodations, collective bargaining for better employment protections, access to health care services⁴¹ — a majority of agricultural workers receive unfair wages,⁴² live in low-income families,⁴³ are likely to delay or forgo medical care,⁴⁴ and have an increased prevalence of respiratory illnesses,⁴⁵ damaging psychological disorders,⁴⁶ and stress disorders and depression.⁴⁷ These health inequities were on clear display during the COVID-19 pandemic, where immigrant workers were called upon to be “essential” to feed the nation without any workplace safety and protections like paid sick leave, workers compensation benefits,⁴⁸ and personal protective equipment.⁴⁹ This decision not to protect “essential” workers is a function of structural racism, where food system production businesses/employers are provided with economic support, while systemically minoritized communities like agricultural workers are structurally disadvantaged and prohibited from accessing benefits from the immigration, employment, food, health care, and public health systems.

In the sections below, I demonstrate how the unmet health-harming legal needs facing agricultural workers, such as dangerous working conditions, unfair wages, and poor access to and quality of health care services, are indeed a product of legal regimes. In other words, these unmet health-harming legal needs are a product of what or who the law chooses to protect versus exploit — either through direct exclusion of agricultural workers from legal protections and/or through limited legal oversight and accountability of the agricultural industry. I end the section highlighting the structural limitations of MLPs’ current model in meaningfully supporting and protecting populations like agricultural workers, who are kept away from state power as a result of structural racism.

A. Direct Exclusion of Agricultural Workers from Federal and State Legal Protections

Labor protections granted through federal law have routinely excluded agricultural workers, maintaining workers in a racialized economic hierarchy.⁵⁰ As explained above, “occupational segregation and the persistent devaluation of workers of color are a direct result of intentional government policy,”⁵¹ specifically the legacies of slavery, Jim Crow, and New Deal.⁵²

On the federal level, two landmark pieces of the New Deal legislation — National Labor Relations Act of 1935 (NLRA) and Fair Labor Standards Act of 1938 (FLSA) — have ensured and maintained the exclusion of agricultural workers from labor protections.⁵³ For instance, the provisions of the NLRA allowed white workers to join unions and collectively bargain for higher wages and paid leave.⁵⁴ However, NLRA provisions excluded agricultural and domestic workers, a majority of whom were people of color.⁵⁵ Specifically in the 1930s, about 65% of all Black workers in the South were employed in the domestic or agricultural industry.⁵⁶ Although the Migrant Seasonal Agricultural Worker Protection Act was later passed in 1983 to provide some protections for “migrant and seasonal agricultural workers by establishing employment standards related to wages, housing, transportation, disclosures, and recordkeeping,”⁵⁷ the Act still did not make NLRA applicable to agricultural workers.⁵⁸ As a result, agricultural workers do not have the same federal protections that are offered to workers in other industries through the NLRA, including the protection from being fired without consequence if workers decide to form unions.⁵⁹ Similarly, agricultural workers are exempt from overtime pay under the FLSA.⁶⁰ Finally, agricultural workers employed on small farms and farms with fewer than seven workers “in a calendar quarter” are not guaranteed to receive minimum wage.⁶¹ On the other hand, temporary agricultural workers (who are hired through the H-2A Visa Program)⁶² are paid the Adverse Effect Wage Rate, which in 2020, was “even lower than the unfairly low national average wage paid to farmworkers ($13.68 per hour in comparison to $14.62 per hour).”⁶³

Even on a state level, agricultural workers are categorically excluded from workplace protections, such as overtime pay and minimum wage laws in most states. Only six states — California, Colorado, Hawai’i, Minnesota, New York, and Washington — have laws that entitle agricultural workers to some type of overtime pay (in phases and with varying thresholds).⁶⁴ Additionally, states including agricultural workers in their minimum wage laws “follow the FLSA framework, including all of the exemptions to the federal minimum wage. In other words, on both the state and federal levels there are numerous exemptions for agricultural workers that make them ineligible for minimum wage protections.”⁶⁵ Finally, like federal labor law, many states also prohibit farmworkers from receiving benefits, such as workers’ compensation for injuries or illnesses occurring on the job.⁶⁶

Being systemically devalued as “low-wage” work as a result of the landscape of labor laws on federal and state levels has serious economic implications for agricultural workers, who are majority immigrant and Latinx.⁶⁷ The lack of fair and just wages, including overtime pay and workers’ compensation, has created and sustained economic disparities among immigrant agricultural workers. The migrant and unauthorized farmworker communities, in particular, have a poverty rate that is almost twice the national poverty rate.⁶⁸ Furthermore, without collective bargaining power and legal power in the form of explicit protections under federal law, agricultural workers are also denied critical workplace protections like reasonable accommodations, worker’s compensation, paid leave, and health insurance.⁶⁹

In the absence of basic and essential protections, agricultural workers are left to perform strenuous labor on the fields without breaks in extreme weather conditions, which in turn has deleterious health impacts. Research shows that working overtime in the fields without work breaks is associated with both acute and chronic kidney illnesses.⁷⁰ Additionally, exposure to high temperatures contribute to heat-related illnesses, including heat strokes.⁷¹ As a result, the annual heat-related death rate for U.S. agricultural workers is 20 times higher than the rate for all civilian workers in the nation.⁷²

Lack of workplace protections are especially harmful for pregnant workers.⁷³ In particular, pregnant farmworkers are exposed to dangerous substances like pesticides and are expected to do physically intensive labor on the fields during pregnancy, both of which contribute to long-term and intergenerational adverse health outcomes for the pregnant farmworkers and their children.⁷⁴ While exposing immigrant workers to health-harming conditions as described above, federal law also prohibits a majority of immigrants—“including lawful permanent residents, asylees and refugees, nonimmigrants, and unauthorized immigrants”⁷⁵—from accessing public benefits like Medicaid and Supplemental Nutrition Assistance Program under Title IV of the Personal Responsibility and Work Opportunity Reconciliation Act of 1996.⁷⁶

B. Limited Legal Oversight and Accountability of the Agricultural Industry

Beyond how federal law is written to exclude agricultural worker safety and well-being, it is equally important to scrutinize how the existing law is enforced. Agricultural industry has limited legal oversight. The Occupational and Safety & Health Administration (OSHA) has the legal authority and power to establish regulations for workplace health and safety pursuant The Occupation Safety & Health (OSH) Act of 1970. However, as reported in the 2017 U.S. Census of Agriculture, nearly 93 percent of the farms — “collectively employing 1.2 million workers”⁷⁷ — are exempt from OSHA enforcement and investigation.⁷⁸ Where OSHA has enforcement authority though, OSHA has failed to adequately protect the health and safety of agricultural workers. For example, OSHA uses its legal power to interpret the OSH Act in a way that does not provide “any right to employees to walk off the job due to potentially unsafe workplace conditions, meaning an employer can discipline an employee for failing to perform their job functions even when the employee has safety or health concerns.”⁷⁹ Additionally, despite record-breaking heat waves across the nation that pose heightened and long-term danger to agricultural workers,⁸⁰ OSHA is yet to establish a federal heat protection standard that meaningfully protects agricultural workers from heat-related illnesses, including heat stress and strokes, and their consequences.⁸¹

In the absence of a federal heat protection standard, states like California and Washington have established permanent rules on heat protection for outdoor workers, whereas Oregon has heat standards for both indoor and outdoor workers.⁸² Colorado has heat regulations for farmworkers only, while Minnesota has a heat standard for indoor workers only.⁸³ However, without strong accountability in the legal system towards agricultural workers, states can exercise their legal power to put workers in dangerous working conditions, including exposing workers to heat-related illnesses and deaths. Most recently, during a dangerous heat wave in Texas, Governor Gregg Abbott signed a law that eliminates local ordinances requiring water breaks for outdoor workers, as well as limits local governments from passing other workplace protections.⁸⁴

The interplay of immigration laws and status with enforcement of labor protections, or lack thereof, also requires attention. Given that a majority of workers in farm labor are undocumented,⁸⁵ workers without legal documentation are less likely to report injuries or raise concerns about their workplace conditions due to fear of retaliation and loss of job and income — a risk they cannot afford.⁸⁶ As a result, with limited legal accountability, large corporations hold significant power within food and meat production — monopolizing and exploiting immigrant labor to keep the food system functioning.⁸⁷

The exclusion of agricultural workers from meaningful legal protections rooted in their safety and well-being — whether through categorical exclusion or unenforcement/ underenforcement of laws — thus serves an important role in making agricultural workers exploitable and expendable for the state. Such power dynamics at play make it essential to explicate, and to some extent, problematize how MLPs currently operate to address health-harming legal needs.

C. Structural Limitations of the MLP Model

Access to legal support offered by MLPs to prevent future health risks is critical for addressing health inequities. However, these supports are temporary band-aids existing within the bounds of the same systems that create the unmet legal needs. In other words, direct legal services in an MLP model can generally help patients in meeting their basic needs by enforcing existing law, including applying for public benefits like Medicaid and food stamps, worker’s compensation, fighting substandard housing conditions and utility interruptions, and so on. But such support is not guaranteed for populations, like agricultural workers, who are excluded from legal protections to begin with as a function of structural racism.⁸⁸ Moreover, attempting to increase access to legal services, without eliminating the power monopoly, can create unintended precarity for minoritized communities like agricultural workers. As explained by Farmworker Justice, which has explored the benefits of MLPs for farmworkers specifically, employers might stifle workers’ access to health care if they feel threatened by the connection of workers to legal services.⁸⁹ Such manipulation and exploitation of workers, again, highlights the extent of keeping minoritized communities away from state power.

MLPs have generally been led by “elite” doctors and lawyers, and the turn to community-engaged and community-informed work is more recent.⁹⁰ Nonetheless, typical MLP models strive to engage in policy advocacy through a “patients-to-policy” approach.⁹¹ In a “patients-to-policy” approach, MLP lawyers employ individual-level advocacy to “listen to the concerns of clients and identify policies and practices that have harmful impacts — and then advocate for long-term systemic solutions.”⁹² Calling upon MLP lawyers to be the “eyes and ears of public health law and policy”⁹³ and propose remedies to the gaps they identify in clients’ concerns, however, unfairly de-centers communities’ power in designing and implementing solutions that communities deem important and necessary. Thus, such an emphasis on the skill set and “expertise” of lawyers to “issue spot” and “problem solve” concentrates power among these actors, and in doing so, concentrates power within legal regimes that created the unmet health-harming legal needs in the first place. Additionally, such an approach also takes for granted the legal systems that thrive from the expendability of immigrants to create effective solutions, as defined and wanted by immigrants, for immigrants. As I will discuss in the next section, agricultural workers have long been visionaries in resisting within and dreaming beyond violent legal regimes. MLPs’ approach to advancing structural change, thus, should pay heed to the leadership of communities facing and experiencing health inequities.

Without disrupting the regimes that create the unmet health-harming legal needs in the first place, the support offered by MLPs does little to unsettle power dynamics that maintain health inequities for systemically minoritized communities, including agricultural workers. Accordingly, I propose that MLPs should shift their model to challenge legal regimes and address structural racism by adopting a health justice lens, which I define and outline in the next section.

Without disrupting the regimes that create the unmet health-harming legal needs in the first place, the support offered by MLPs does little to unsettle power dynamics that maintain health inequities for systemically minoritized communities, including agricultural workers. Accordingly, I propose that MLPs should shift their model to challenge legal regimes and address structural racism by adopting a health justice lens, which I define and outline in the next section.

III. Shifting MLP Model to Challenge Legal Regimes: A Health Justice Perspective

For MLPs to meaningfully advance health justice, MLPs must seriously contend with their structural limitations in supporting populations who are systematically kept away from state and legal power. Instead, MLPs should build and expand their interdisciplinary model to center grassroots policymaking and organizing. In this section, I offer insights on how MLPs can center the goals of health justice to address structural racism and ensure sustainable change. I define health justice as an intersectional movement led by impacted communities, rooted in building people power and disrupting legal regimes, to construct systems that invest in joy, safety, and collective liberation.

People power has always been at the forefront of social justice movements, including the pursuit of health justice, especially within the agricultural workers communities. From labor union organizing efforts in the 1940s and 1950s that put an end to the Bracero Program and its abusive working conditions for agricultural workers to current union organizing efforts that have successfully improved workplace protections for agricultural workers,⁹⁴ (im)migrant workers have always led the way in creating innovative labor organizing models outside the bounds of legal regimes.⁹⁵ In the absence of state power, agricultural worker organizations have developed power-shifting programs like the Fair Food Program (developed by Coalition of Immokalee Workers in Florida)⁹⁶ and Milk with Dignity Program (developed in partnership with Migrant Justice in Wisconsin).⁹⁷ By participating in these programs, workers build their (collective) power and set their own work and production standards, as well as accountability measures for companies working with them.⁹⁸ Similarly, National Day Laborer Organizing Network⁹⁹ is leading efforts to bring together directly impacted immigrant workers and other stakeholders to “offer a vision of labor rights enforcement that lifts all workers.”¹⁰⁰

These migrant-led advocacy and organizing efforts showcase how (im)-migrant workers resist legal regimes that make them exploitable and shift power back to (im)migrant workers. Simultaneously, they provide an important blueprint for MLPs to follow. MLPs should leverage their legal capacities and infrastructure to support and advance the migrant-led policy agenda. I argue that movement lawyering offers tangible steps for MLPs to center health justice by building people power as demonstrated in the examples of farmworker advocacy above, and support a radical imagination and transformation of laws and systems.

Movement lawyering refers to “lawyering that supports and advances social movements, defined as the building and exercise of collective power, led by the most directly impacted, to achieve systemic, institutional, and cultural change”¹⁰¹ Legal scholar Sameer Ashar explains that movement lawyering is guided by three key principles: building critical infrastructure, co-generating resources, and accompaniment and transformation.¹⁰² Within a movement lawyering ethic, “lawyers both deploy conventional legal tools and mechanisms while nurturing critical visions by which to alter law and social discourse.”¹⁰³ The intentional and power-shifting practice of leveraging legal skills in service of movements and actions led by impacted communities are well-suited to be integrated within the MLP movement. In the paragraphs below, I provide considerations on how MLPs, as interdisciplinary collaborations, can transform their existing structure to center movement lawyering principles: 1) building critical infrastructure, 2) co-generating resources, 3) accompanying impacted communities to transform laws and systems.

First, hospital-based MLPs and academic MLPs can offer organizational support in building intersectional coalitions. Many hospital-based MLPs exist within community health centers (CHCs)¹⁰⁴ that serve majority-immigrant neighborhoods.¹⁰⁵ CHCs are federally qualified health centers that act as important safety nets for immigrants who cannot afford to pay for health care services or do not have access to insurance.¹⁰⁶ Critically, CHCs help in building community trust, with CHC workers being active members or participants of the communities they serve.¹⁰⁷ Some health centers also invite legal services partners to meetings with agricultural worker patients.¹⁰⁸ In a movement lawyering orientation, I argue to flip this dynamic such that the presence and leadership of legal service and health care partners is de-centered. Specially, hospital-based MLPs should actively build relationships with local, state, and national grassroots and movement organizations. Doing so would not only strengthen community-building efforts valued by CHCs, but also create an intentional space for impacted communities to identify patterns of health inequities and inform interventions needed for addressing those inequities. Similarly, academic MLPs often have access to stable funding and institutional capacity due to their university affiliation.¹⁰⁹ With a movement lawyering approach, academic MLPs can leverage their research infrastructure — including grants, trained researchers and staff, and physical space — to support power-mapping strategies of movement organizations, as well as the advancement of migrant-led policy agendas and interventions. With this critical infrastructure, as well as growing federal investment within the MLP model,¹¹⁰ MLPs hold the potential to help in organizing multifaceted movements for immigrant workers. Specifically, MLPs can use critical infrastructure, such as hospital and research resources, to build trust with impacted communities, connect agricultural workers with movement organizations, and bring minoritized communities to the forefront in decision-making. In this way, MLPs can intentionally de-center the power held by lawyers and health care partners in MLPs, while working towards amplifying people power to disrupt legal regimes and address structural racism.

Second, MLPs already support interprofessional and interdisciplinary education, which can be leveraged to co-generate resources.¹¹¹ Instead of focusing exclusively on training students and MLP staff on issue-spotting, hospital-based MLPs and academic MLPs can support training opportunities in power-building strategies with the leadership of agricultural workers and movement organizations. In particular, emphasizing power-building strategies like coalition and movement building, advocacy and grassroots lobbying, local, state, and national campaign development, impact litigation, and community-led research¹¹² is an important shift for MLPs to undertake to ensure that agricultural workers are at the center of decision-making and agenda setting. With power-building strategies integrated in the MLP model, MLPs can play a vital role in strengthening the capacity of movement organizations and campaigns and building people power needed to disrupt legal regimes and address structural racism.

Finally, MLP lawyers can leverage their legal power to accompany agricultural workers in their acts of resistance and reimagination of laws and systems. The current MLP model uses a “patients-to-policy” approach, which maintains power among lawyers and health care partners to investigate the gaps prevalent within laws and policies and propose remedies to bridge these gaps.¹¹³ In contrast, a movement lawyering orientation calls upon MLPs to shift power back to impacted communities, for example, agricultural workers and migrant-led organizations, who are already leading the way in identifying problems and developing solutions. In other words, MLPs should pay attention to the problems identified by agricultural workers and movement organizations and support the implementation of community-led solutions and interventions. The examples of migrant-led advocacy and organizing efforts discussed previously highlight how agricultural workers and movement organizations center communities in imagining and leading interventions outside the bounds of violent legal regimes—for instance, by creating new food programs with their own work and production standards and transforming labor rights for migrants.¹¹⁴ MLPs should leverage their legal power to support and advance the migrant-led policy agenda, instead of identifying patterns and problems based on the perceptions and individual advocacy of lawyers and health care partners. Such a reconstruction of the model enables MLP lawyers and partners to accompany and “hold space”¹¹⁵ for agricultural workers—by extending their legal power to agricultural workers who are intentionally kept away from state power due to structural racism. In doing so, MLPs can de-center their role and power, and work towards amplifying people power to disrupt legal regimes and address structural racism.

Community power and leadership are integral to developing and implementing health-affirming practices, values, and systems. The method and practice of building community-led agendas will vary based on the specific needs, goals, and circumstances of each community. What is critical, however, is the need to shift power traditionally held by lawyers and health care partners in MLPs towards systemically minoritized communities facing health inequities. Some MLPs are beginning to center community power building in their models. For example, MLP Hawai’i strives to shift decision-making power towards impacted communities by decreasing staff presence.¹¹⁶ Adopting movement lawyering principles—specifically by leveraging critical infrastructure, co-creating resources, and accompanying impacted communities to transform laws—offers one way for MLPs to disrupt legal regimes, amplify the collective power of minoritized communities, and support the development of protections and systems as designed by impacted communities themselves. Shifting MLPs’ focus to challenge regimes and build people power in this way will allow MLPs to address structural racism, and ensure that the pursuit of health justice leads to meaningful structural change.

Conclusion

Challenging legal regimes is a critical starting point to address health inequities and to assist in the creation of systems rooted in joy, safety, and collective liberation. This article offers important considerations for MLPs to challenge legal regimes to promote the health and safety of minoritized communities like agricultural workers, who are routinely kept away from state and legal power as a function of structural racism. To address health inequities effectively and structurally, MLPs must move beyond poverty-focused narratives and “patients-to-policy” approaches that concentrate power among health care and legal professionals. Instead, MLPs must center health justice principles in their model, which includes challenging legal regimes to address structural racism, building people power, and reconstructing systems with the leadership of impacted communities.