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From rats to heaters, doctor-lawyer team fights barriers to family health care

By Lena H. Sun
Washington Post Staff Writer
Wednesday, May 26, 2010; B01

Thirteen-year-old Haji Conteh had all the irritating symptoms of seasonal allergies when her father took her to see a pediatrician at a D.C. clinic last summer.

But when the doctor questioned Haji and her father, she began to suspect there might be a cause other than pollen for the girl's sneezing and itchy eyes: the rats and mold in the family's Northwest Washington apartment.

The pediatrician didn't have the time or expertise to probe more deeply. But she did refer the family to a specialist-- not another doctor, but a lawyer.

The family is among 1,400 referred by doctors and others at Children's National Medical Center to the Children's Law Center. As part of a medical-legal partnership that began in 2002, lawyers work alongside doctors at four District clinics run by the hospital. Their shared goal is to overcome legal and social challenges that threaten the care of their patients -- low-income children, predominantly African American, and virtually all covered by Medicaid.

The lawyer who took on Haji's case secured housing inspections that documented numerous violations in the family's Adams Morgan apartment. She forced the landlord to replace water-damaged ceilings in which mold had festered and to seal holes in the floor and walls where rats scampered.

Within several months, "everything was fixed," said Haji's father, Idrissa Munu. Her allergies are now manageable. Family members no longer jump on the couch, feet tucked beneath them, he said, to escape the scurrying rats.

The doctors who work in the clinics say they welcome the lawyers' help. More than ever, they say, the pediatric patients going through their doors complain of symptoms that stem from social and legal problems. Catching them early can prevent full-blown emergencies that are more difficult and costly to treat, say supporters of such partnerships.

"If a child comes in and they're failing kindergarten, or their asthma isn't getting better because of substandard housing conditions, it gives us a chance to do something about them," said Alsan Bellard Jr., medical director of two clinics in Southeast Washington.

The partnership that operates through the four clinics in the District -- part of a grass-roots program launched in Boston in 1993 that has 85 partnerships in 37 states -- is the only one in the Washington area. Some other D.C. primary-care physicians say they would like to team up with lawyers, but the law center can't afford to hire more full-time staff lawyers, Executive Director Judith Sandalow said.

Even existing funds could be in jeopardy. The law center relies in part on a D.C. government grant that could be cut next year because of tight budgets. The D.C. Council is scheduled to take its final budget vote Wednesday.

In Washington, lawyers from more than 70 firms assist the Children's Law Center. The American Bar Association supports the partnerships and recently opened an office to help firms interested in participating.

The success of the integrative approach is one reason advocates say there is bipartisan support, even in health care-weary Congress, for a federal demonstration project to measure the effects on patients, physicians and health centers, said Ellen Lawton, executive director of the National Center for Medical Legal Partnership.

'It just didn't sound right'

In Washington, five staff lawyers and two investigators work with pediatricians at the health centers. Two centers are in Northwest Washington -- at the main hospital on Michigan Avenue and in Adams Morgan -- and two in Southeast, on Good Hope Road and Martin Luther King Jr. Avenue.

The legal office is often just steps from an exam room. On a typical day at the Michigan Avenue clinic, doctors see 100 to 150 children and make about a dozen legal referrals. Those don't include quick consultations that take place in the hallway.

Some referrals happen while a lawyer is on-site; others are sent a day or two later via e-mail or phone calls. Last year, the law center worked with 300 patient families, project director Tracy Goodman said.

The lawyers train the pediatricians to screen for red flags during an exam, including housing conditions and school absenteeism. Doctors have only 10 to 15 minutes to devote to each patient.

"We train them to go with their gut," said staff lawyer Lauren Onkeles. "If they think there are legal issues, we tell them not to sweat the details. So a lot of our referrals are, 'It just didn't sound right.' "

That was the case last month, when pediatrician Jennifer Tender noticed an infant with breathing problems during a well-child exam at the Michigan Avenue clinic. The parents told her they couldn't turn down the heat in their apartment. Tender told the law center's Goodman about the potential for an "acute life-threatening event," Goodman said.

Neither the doctor nor lawyer could provide details about the case because it is ongoing.

Many referrals have to do with access to school services, especially in special education.

Lawyers are investigating a case about a child who might be held back a grade for missing too much school because of her HIV-related illnesses. A parent told the doctor that the child wasn't able to receive her daily medicine at school. Only the school nurse was allowed to dispense the medicine, the parent said, and the nurse did not work every day.

Sometimes, all it takes is one question.

A few years ago, staff lawyer Onkeles was referred a case that began when a 15-year-old girl went to the Adams Morgan clinic for a routine checkup. How is school? the pediatrician asked, only to find out that the girl was no longer attending and was working at a Chipotle restaurant.

Onkeles later determined that the mother, a native Spanish speaker, had unwittingly signed a school withdrawal form that was never translated or properly explained. Within weeks, the girl was back in school, the lawyer said.

Although many health clinics have social workers to help families with social and legal needs, legal expertise is becoming more necessary as safety net systems become more complicated, Lawton said.

Other benefits

In the Munu household, the battle with the rats had gone on for nearly three years. The landlord ignored the problem, Idrissa Munu said, even after Munu killed three with a baseball bat and took them to the management office in a plastic bag.

Lawyer Kathy Zeisel helped the family resolve two other problems that were flagged during the doctor's exam.

She helped the pharmacist and insurance company understand that it was medically necessary for Haji to receive prescription-strength Zyrtec, an allergy medicine, in syrup form because she cannot swallow pills.

The public school had also concluded that Haji, who has Down syndrome, was "incapable of learning," Zeisel said. The parents had unsuccessfully challenged that assessment.

Zeisel helped the parents obtain an independent evaluation, which found that Haji could learn better life skills if she received speech therapy and if teachers used pictures to communicate.

Working with the lawyers has made Munu a better advocate for his family in all settings, he said. He asks more questions. And he documents any concerns he has -- whether with insurance or his daughter's teacher -- at the doctor's office.

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