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Healing Hands: April 2000  

Clinicians as Advocates

Whenever we speak up or write in support of a person or cause, we are engaging in the practice of advocacy — a term first used within the context of civil and ecclesiastical law to denote the act of calling for justice or mercy. Individual advocacy is an effort to persuade others to attend to one's own or another person's needs. Policy advocacy merely expands the universe of individuals who would be affected by a proposed action, including those we don't know. In this broader sense, “advocacy is the educational process through which data, experiences and insight are shared with those who craft public policy [through laws, administrative rules and regulations, or judicial actions], so that they may make informed decisions.” 1



“Health Care for the Homeless clinicians have unique and very compelling perspectives from working with people who have fallen out of mainstream systems,” observes Nate Nickerson, MSN, ANP, RN, who directs the Portland Public Health HCH program in Portland, Maine. “They also have special spheres of influence and status that increase their effectiveness as advocates.” Clinicians are trained to think diagnostically about individual problems. The same analytic skills can be applied to identifying the etiology of system and policy failures, he suggests, which is an essential part of reforming them.


Nickerson is a nurse practitioner who became a project administrator. “Ten years ago, I was the HCH project,” he recalls. Even then, he made time to testify before the legislature and the city council or submit written testimony regarding issues his patients were encountering. As an administrator, he considers it part of his responsibility to create and coordinate venues in which clinicians can advocate most effectively. “To maximize the impact of clinician advocacy and minimize the amount of time away from their clinical service, administrators should be very clear about what they ask clinicians to do,” he says.


Matias Vega, MD, Medical Director of the Albuquerque HCH in New Mexico, describes himself as “an advocate who happens to be a clinician.” Client advocacy goes with the job, he says. “Most clinicians don't think of themselves as effective at policy advocacy because they don't do it.” Vega plans to address this omission at the HCH 101 institute in Denver on April 26, prior to the National Health Care for the Homeless Conference. He thinks advocacy should be written into the job descriptions of HCH clinicians, and that project administrators should give them time and recognition to advocate as an integral part of their work. “We must improve service systems and address the root causes of homelessness to make a long-term impact on the problems we see in our practices,” he contends.



Albuquerque HCH staff take Senator Pete Domenici (R-NM) on a tour of their project. Left to right: Sigrid Olson, Executive Director; Sen. Domenici; Dr. Matias Vega, Medical Director

Photo by Jeff Gittelman, BSN, RN



Policy analysts call this “upstream thinking,” in reference to the parable of the villagers who devoted themselves to rescuing increasing numbers of drowning people from a river. Over many years, they developed ever more sophisticated technologies and services to resuscitate victims downstream. So preoccupied were the heroic rescuers with treatment and rehabilitation, it never occurred to them to find out why the people had fallen into the river in the first place.2 Vega's reminder is a call to HCH clinicians to “walk up the river” and find ways to prevent the human catastrophes associated with homelessness.

Most of Mat Vega's advocacy doesn't have anything to do with medical issues. “We are often most effective when we advocate outside our vested interests or those of our projects,” he observes. He prefers to think of health care for the homeless in the most holistic sense, addressing all needs of the homeless community — housing, transportation, child care, job training, legal services and life skills training — as well as mental health and substance abuse services. This may require a leap of faith for clinicians without direct experience in these issues, he admits, “but they can learn! Everything I know about advocacy I learned from my patients and other advocates,” he claims. “They didn't teach this stuff when I was in medical school.”


“My profession defines my role as an advocate, both for clients and for broader social policy,” explains Tony Halton, MSSW. The National Association of Social Workers' professional code of ethics stipulates that “social workers should act to ensure that all persons have access to resources, services and opportunities they require.” Moreover, “they should advocate for changes in policies and legislation to improve social conditions of clients and to promote social justice.”


Tony Halton, MSSW, convenes stakeholders' work group in a Nashville domestic violence shelter, as part of advocacy for outreach to sheltered homeless children in Tennessee. Participants include shelter providers, MCO representatives and outreach workers from local health and human service agencies.

Photo by Scott Orman



Halton worked in homeless health care as a substance abuse counselor at Nashville Metropolitan Health Department's Downtown Clinic for ten years before joining the National Health Care for the Homeless Council staff as coordinator of a demonstration project to promote health care entitlement outreach to sheltered homeless children in Tennessee.


In addition to facilitating a domestic violence batterers' group and a support group for substance-impaired nurses, Halton works primarily with state and local agencies that provide services to homeless families. He convenes and attends inter-agency committees that are working to develop strategies for reducing system barriers that prevent homeless children from obtaining health insurance and services under TennCare, Tennessee's Medicaid/CHIP managed care program.


“After years of advocating for individual clients who were denied essential services, I eventually realized that the policies I was fighting were developed by larger systems that needed to be changed,” explains Halton.His advice to HCH clinicians is to collaborate with other advocates for special needs populations through coalitions or task forces working for broader policy change. “Direct-service providers help policy makers understand what is clinically feasible, and what will work for persons experiencing homelessness.”




1. Marsha McMurray-Avila. Organizing Health Services for Homeless People: A Practical Guide, 1997, 304-314.
2. Kevin Lindamood. State & Local Advocacy Manual (SLAMbook), September 1999. Excerpts available on the HCH web site.

3. Children's Defense Fund. An Advocate's Guide to Lobbying and Political Activity for Nonprofits, 1991.

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