Ryan White. Real Lives. Hear their stories and take action

Ryan-White-Red-on-whiteRyan White. Real Lives. is a national campaign presenting narratives on the importance of the Ryan White HIV/AIDS Program among communities affected by HIV, particularly states in the Deep South that have not expanded Medicaid.

The campaign shares the stories of individuals and families around the country and from all walks of life who are living with HIV. These stories highlight the personal impact of Ryan White services and the ongoing need for the program as a key part of our response to HIV.

Want to help? Follow the links below the stories to ask your Congressional representatives to support the Ryan White Program, and ask your state officials to implement Medicaid expansion if your state hasn’t already done so.

Meet the individuals and read their stories.

An Interview with Fulbright Scholar and FLPC Alumna Grace Nosek, HLS J.D. ’14

HLS Alumna Grace Nosek J.D. ’14 was awarded a Fulbright Fellowship to conduct research. She is one of 22 students from across Harvard University to receive the prestigious grant.

As a student at Harvard Law School, Grace participated in the Food Law and Policy Clinic. Taking pride in her achievement, the Office of Clinical Programs (OCP) interviewed her about her work with the Fulbright Fellowship and her time at the law school. Please read the interview below.

OCP: Why did you choose to study law and what sparked your interest in the Fulbright Scholarship?

Grace Nosek, HLS J.D. '14

Grace Nosek, HLS J.D. ’14

GN: As a child, I was mesmerized by the color of a spring afternoon and the iridescence of a twilit forest. This love of the natural world led me to study environmental issues throughout my academic career. I also cared deeply about the connection between social justice and environmental issues. Watching one’s crops wither and die, not having clean air to breathe or clean water to drink—these realities represent a uniquely oppressive kind of helplessness. Wanting to both protect the natural world and empower citizens with a voice in government decision-making, I decided to study law.

Many of the most intractable environmental issues of our time require international cooperation; they also present opportunities for countries to learn from one another. Thus the Fulbright fellowship seemed like a perfect opportunity to continue working on the issues that brought me to law school.

OCP: How did your time at Harvard Law School influence your decision to pursue a Fulbright Scholarship?

GN: My time at the Food Law and Policy Clinic showed me how much I loved working on policy research. I also found myself returning to a theme that emerged throughout my classes, and especially during my experiences with the Clinical and Pro Bono Program, which was the inextricable connection between all social justice issues. I wanted to continue exploring those connections, taking a holistic vision of environmental and environmental justice issues. There are few better ways to force yourself to gain new perspective on issues than to explore them through the lens of another country’s legal regime. It has been incredibly intellectually engaging to begin that process as I settle into my fellowship in Victoria, BC.

OCP: What did you find most challenging about your experience in the Clinical and Pro Bono Programs?

GN: The clinical programs push you from theory to practice—they give you a lot of responsibility, which is very different from the insulated world of the classroom. I was challenged by but also reveled in that responsibility. While at the Food Law and Policy Clinic, I honed my research and interviewing skills as a co-author of a comprehensive policy report on food waste in America, produced in partnership between the Food Law and Policy Clinic and the Natural Resources Defense Council. The report required that I reach out to a diverse set of stakeholders, including scientists, industry representatives, government actors at the state and national levels, and non-profit advocates. I felt pushed but also supported, which for me is the sweet spot for personal and academic growth.

It was nothing short of thrilling to dive into my work, knowing that all my hours tracking down various data about food date labels would make a tangible difference in American food policy. The clinics also provided a space for less conventional avenues of learning and advocacy that I really appreciated. When I approached my supervisor at the Food Law and Policy Clinic, Emily Broad Leib, about making a short film to raise awareness on food waste, she was incredibly encouraging. Experimenting with creative advocacy and film (a medium I had never before worked with) was one of the most meaningful experiences I had at HLS. (You can see the results of this experimentation here.)

My experience with the Clinical and Pro Bono Program taught me to be open and creative and to roll with unexpected challenges. These skills have been invaluable as I’ve explored new legal regimes during my Fulbright fellowship.

OCP: What can you tell us about the work you’ll be doing as a Fulbright Scholar?

GN: I’ll be conducting a comparative study into how governments in Canada and America can ensure citizen participation in energy infrastructure decisions. Supervised by Chris Tollefson, professor at the University of Victoria’s Environmental Law Centre, my research project will include a comprehensive review of the legal and regulatory regimes surrounding pipeline approval.

Cross-Posted from the Harvard Law School Office of Clinical and Pro Bono Programs

CHLPI Welcomes Visiting Scholar Karolina Gombert

Karolina_Passbild_001The Center for Health Law and Policy Innovation is pleased to welcome Karolina Gombert,  a PhD student from the University of Aberdeen in Scotland, to Boston. Karolina is a recipient of Santander’s Mobility Award, given to postgraduate research students to help them gain the experience of a period of short-term study or research at a like-minded institution within the international Santander Universities network. Karolina says she chose Harvard Law School and CHLPI because “What I read and learned about the center sounded amazing and our project ‘Foodways and Futures’ fits right in with the center’s work.”

Karolina’s PhD project is an action research project falling under the “Pathways to a Healthy Life” theme at the University of Aberdeen. The “Pathways to a Healthy Life’” theme aims to cross disciplinary boundaries to enhance the University’s contribution to all aspects of healthy aging and wellbeing, aiming to improve not only life expectancy, but also life expectancy whilst free of disease. The program looks into complex mechanisms by which individuals, lifestyle, the local community, socio-economic and environmental conditions impact healthy aging. Specifically, her study aims to gain a better understanding of the lived experiences and lifestyles of so-called “vulnerable” young people in Scotland, including homeless and unemployed young people, and explore the relationship between them, their local communities, and the surrounding socio-cultural and economic environmental structures, and the influences and impact those factors have the decisions they make about the foods they consume.

She joins the CHLPI team during her study visit until the end of April. We wish Karolina the best of luck with her project and look forward to collaborating her.

Learn more about Karolina’s project,”Foodways and Futures

Here Come the Water Works: A New Legal Strategy for Confronting Agricultural Pollution in Iowa

By Mary Ignatiadis, Intern in the Food Law and Policy Clinic (Winter 2015)

*I would like to thank Professor Jerry Anderson of Drake University Law School for sharing his knowledge and insight.

In Iowa, water pollution comes primarily from two places: cornfields and hog waste. The state is blanketed in 13.6 million acres of corn and is home to 20.9 million pigs. The vast majority of farms use conventional agricultural methods: they rely on chemical fertilizers and use machinery to do the plowing, weeding, and feeding on 85% of the state’s land. A primary ingredient in corn fertilizer and hog manure is nitrate, a nutrient necessary to all living things that moves its way up the food chain from the soil. However, the large amounts of nitrate used to support conventional, industrialized agriculture wash off fields and pig pens into waterways, where high concentrations of nitrate turn rivers and lakes into toxic environments. Much of this runoff occurs during the winter months, when cornfields are left barren and are unable to transform the nitrate into living matter. The Des Moines Water Works (DMWW) became the first entity to hold local governments legally accountable for this pollution when it issued an intent to sue letter on January 8th, 2015. It is a novel, even noble, step, but the suit alone cannot change the agricultural policies and politics at the heart of Iowa’s pollution problem.

The DMWW is suing three counties whose subsurface agricultural drainage systems have been identified as point sources of nitrate pollution in the Raccoon River. Nitrate concentrations have been increasing in Iowa waterways for decades, as corn prices boomed and farmers heaped nitrate-rich fertilizer on their crops to increase yield. The number of Concentrated Animal Feeding Operations (CAFOs), which can hold tens of thousands of hogs each, has grown in Iowa has well. The lagoons and containment facilities where this waste is stored are poorly regulated and often fail, spilling nitrate-rich waste into Iowa’s waterways. Consequently, DMWW had to use $900,000 of taxpayer dollars in 2013 to filter nitrates out of the Raccoon River to protect the city’s drinking water. The filtration system itself cost $4.1 million. Without the filtration system, nitrate concentrations in the City’s drinking water would sometimes be four times what the EPA has deemed to be safe. Toddlers and infants would be at high risk for developing methemoglobinemia, a potentially fatal condition known more commonly as “blue baby syndrome.”

Challenge #1: Role of Government Agencies and Political Influence
There are two main barriers to effective management of agricultural pollution in Iowa. First, the state’s goal of promoting intensive agriculture and the state’s goal of reducing nutrient pollution are currently pursued in such a way that the goals are seemingly incompatible. The Iowa Department of Agriculture and Land Stewardship and the Iowa Department of Natural Resources have no laws regulating nonpoint source pollution, which would give them a solid base from which to establish nutrient reduction programs to unite these goals. Currently, as the Iowa Department of Agriculture and Land Stewardship is not answerable to such a regulation, it has no reason to stop incentivizing high yield, high pollution agricultural practices.

This conflict of interest is echoed at the federal level between the USDA Natural Resource Conservation Service (NRCS) and the USDA Farm Service Agency (FSA); NRCS and FSA promote different, contradictory goals at the federal level, despite being part of the same agency. This has contributed to a vicious cycle of poor land management practices. Farmers are encouraged to increase their production in order to keep up with their neighbors. Overplanting by large, heavy machinery depletes and compacts the soil. Compacted soil does not hold water and thus loses its ability to store nutrients or stay in place. So what’s a farmer to do? Apply more chemicals to offset soil loss and nutrient depletion. Or just spray nitrate-rich manure from CAFO sewage lagoons straight onto fields. As soon as it rains, the nitrate-rich waste joins the eroded soil as it gushes towards the waterways and people downstream. Parts of Iowa are losing over 50 tons of soil per acre per year, added fecal material not included.

Second, officials in many areas of Iowa state government profit from intensive agriculture, either as owners, investors, or recipients of campaign contributions. When Governor Terry Branstad called the DMWW suit “an attack on rural Iowa,” he meant that the suit was an attack on the agricultural businesses that funded his campaign. Governor Brandstad’s largest campaign donor is the president of Iowa Commodities, Inc., a company that brokers large agricultural trade deals. Agricultural trade is big business in Iowa; Iowa corn and hog farmers grossed $9.9 billion dollars in 2013, and therefore wield considerable economic and political power within the state. This is partly demonstrated by the fact that fourteen out of the fifty members in the Iowa Senate are or have been farmers or owners of farm equipment companies.

Challenge #2: Interpretation of the Clean Water Act
The Clean Water Act (CWA) regulates only point sources of pollution, and specifically exempts agricultural stormwater. Yet the subsurface drainages in question (commonly called “tile drainages”) should not be confused with the superficial runoff the CWA intended to exempt as agricultural stormwater. Tile drainages collect water below agricultural fields and drain Iowa’s naturally marsh-like terrain. According to Iowa Code 468.1, county governments are responsible for the construction and upkeep of these drainage systems, as they flow continuously beneath different farms. The nutrient-laden water is concentrated through acres of pipes until it is dumped into the Raccoon River. The Raccoon River is currently a Class Five “impaired waterway” according to the Environmental Protection Agency, meaning that Iowa’s state government is responsible for alleviating the nutrient burden in the river. However, Iowa’s Nutrient Reduction Plan falls short of attaining this goal, as it relies on voluntary farmer participation and is costly. If the court in this case finds the tile drainages to be a point source of pollution, it would establish a precedent for targeting concentrated agricultural runoff from drainage systems.

Challenge #3: Focus of DMWW Suit
DMWW does not have the funds or the power to take on this industry directly. The CEO of DMWW, Bill Stowe, made this distinction when he told the press, “We are not seeking to change agriculture methods, but rather challenging government to better manage and control drainage infrastructure.” What Stowe does not mention is that trying to curb nitrate pollution with better drainage pipes is like trying to cure the flu with a Kleenex.

However, the suit may set a powerful precedent for holding local governments accountable for regulating others’ agricultural pollution. DMWW’s case will ultimately depend on how Iowa’s district court categorizes discharge from subsurface drainage systems.

Common Sense Solutions
The DMWW lawsuit might limit pollution from three of Iowa’s ninety-nine counties, but large and systematic changes in agricultural practices are needed to break this cycle of environmental devastation. These changes could be simple. Nitrogen-fixing cover crops (such as rye) could replace the barren mud flats that form outside of the corn-growing season; currently this practice is used on only 2% of Iowa’s fields. Scientists at Iowa State University and the Environmental Working Group found that converting 10% of land from production to prairie can decrease soil loss up to 95%, nutrient loss to 80-90%, and water pollution up to 44%. Effective conservation measures also include planting trees and grasses along field edges and reducing or omitting field tilling. Alternately, farmers could grow biofuels such as switchgrass, which do not require as much nitrate as corn and therefore would need less nitrate-rich fertilizer. Policies that would promote such practices include: nitrogen fertilizer taxation; developing an active role in the commodity market for nitrogen-fixing crops; and increasing oversight of manure storage and application.

Championing these age-old techniques are groups such as the Practical Farmers of Iowa, whose efforts to preserve the integrity of their land, and their profession, are chronicled in Farming for Us All: Practical Agriculture and the Cultivation of Sustainability. The book explores the sociological, economic, and political reasons that sensible agricultural methods that ensure long-term productivity are not widely employed in the Midwest today. One reason is the lopsided structure of financial incentives for Corn Belt farmers, who, between 1997 and 2009, received $51.2 billion in agricultural subsidies to increase production, while the government programs that help farmers to implement soil conservation practices provided only $7 billion. This disparity is not surprising, considering that agricultural companies spent well over $50 million lobbying Congress in 2013 alone. The 2014 Farm Bill improves upon this by offering $4 billion in funding for conservation over the next five years, but may in effect be decreased by appropriation committees in the House and Senate.

Finding the Power to Drive Policy
Litigation on the grounds of environmental pollution is aimed only at the symptoms, rather than the causes, of irresponsible agriculture. The conventional farmer of today believes in the power of technology to overcome the natural limits of their land’s productivity. This mentality fueled the farmers and government policies which created the Dust Bowl of the 1930’s. In fact, dust bowls have occurred in the Midwest at least once every decade since. Polluted water is just one of many environmental disasters brought on by conventional farming methods, and yet the culture among farmers of over-farming has not changed, nor have the government policies which support it. Public support for groups such as the Practical Farmers of Iowa will be more influential in reducing water pollution in the Corn Belt than litigation. State and federal officials must be incentivized by constituent support to codify smart farming policies.

The views reflected in this blog are those of the individual authors and do not necessarily represent those of the Center for Health Law & Policy Innovation or Harvard Law School. This blog is solely informational in nature, and not intended as a substitute for competent legal advice from a licensed and retained attorney in your state or country.

Food Law and Policy Clinic Joins Other Harvard Faculty for Lightning Lectures on Food

Emily Broad Leib, Director of CHLPI’s Food Law and Policy Clinic (FLPC), joined other Harvard faculty members and lecturers on February 27 for the Food+ Research Symposium. She was an organizer and also presented “The Role of Law and Policy Research in Our Food System; Case Study on Food Waste,” based on the Food Law and Policy Clinic’s work on implementation of better expiration date policies and other policy reforms which could significantly decrease food waste.

The Food+ Research Symposium, which was hosted by the Weatherhead Center for International Affairs, the Harvard Kennedy School Sustainable Science Program, and the Harvard Center for the Environment, brought together 22 faculty speakers from eight Schools last Friday to deliver seven-minute presentations on the nexus of food, agriculture, environment, health, and society.

The symposium served as a platform for discussing the future of food as it relates to current infrastructure, technological innovations in science and agriculture, and global health and nutrition. The Food+ symposium was organized in conjunction with the Harvard Food Better campaign, a yearlong education and awareness initiative to foster a discussion of the food system and how to improve it. Launched by FLPC, Harvard University Dining Services, and Harvard Office for Sustainability, the University-wide campaign includes a variety of events and activities that explore food production, distribution and markets, nutrition and health, and food waste.

FLPC has also been involved this year in promoting interdisciplinary collaboration at Harvard through helping to organize the Deans’ Food System Challenge, hosted by Harvard Innovation Lab. Co-sponsored by Dean Martha Minow of Harvard Law School and Dean Julio Frenk of Harvard School of Public Health, the Deans’ Food System Challenge invites creative and entrepreneurial students to develop innovative ideas to improve the health, social, and environmental outcomes of the food system in the United States and around the world.

Read more about the symposium and other lecturers in the Harvard Gazette

Update: April 20, 2015
Video of Emily Broad Leib’s talk on “The Role of Law and Policy Research in Our Food System: Case Study on Food Waste” is now available.

PATHS Toward Successful Policy Advocacy: CHLPI Hosts Workshop at Together on Diabetes™ Summit

The Center for Health Law and Policy Innovation team presented a half-day Policy Advocacy Workshop at the Bristol-Myers Squibb Foundation’s Together on Diabetes™ Summit. Three Harvard Law School students reflect on the day and the important work performed by the attendees as they sought to refine and develop implementation plans for their policy goals.


By: Kristen Gurley (JD ’15), Jason Nichol (JD ‘15), & Tommy Tobin (JD ’16)


ATLANTA, GA: On February 23rd, the Harvard Law School Center for Health Law and Policy Innovation (CHLPI) hosted a policy advocacy workshop in advance of the Together on Diabetes™ 2015 Grantee Summit. The Summit convened Bristol-Myers Squibb Foundation grantees from across the nation to discuss health equity and the patient experience for people living with diabetes.

CHLPI and its Providing Access to Healthy Solutions (PATHS) project were among those funded through Together on Diabetes™, a philanthropic program of the Bristol-Myers Squibb Foundation that seeks to promote health equity and improve health outcomes.

The purpose of the Pre-Summit Workshop was to help attendees establish and refine the policy goals that will make the interventions and services tested in their innovative research both scalable and sustainably funded in the long-term. In setting the table for future action, CHLPI presenters instructed attendees about the development and mechanisms of policy action and advocacy.

In her opening remarks, CHLPI Clinical Instructor Sarah Downer emphasized that “policy is the legal and regulatory framework” within which the attendees work. Downer then reminded the room that “it’s important to remember that we can reform” this framework.

CHLPI aimed to empower attendees to use policy advocacy in an effective way to help move their own organization’s policy goals forward.

Presenters first provided an overview of the levels of government policy-making, including federal, state, and local. Two grantee organizations then told their own success stories of policy changes. Finally, the grantees gathered in small groups to articulate their policy goals and strategize potential pathways for policy advocacy.

Clinical Fellow Katie Garfield opened the Workshop with a presentation on building effective advocacy strategies. According to Garfield, policies and programs are two concepts that often get confused.

Garfield refined the distinction between the terms. She outlined that “programs” promote a specific activity, while “policies” are generally broader and more sustainable because they set up a framework that can continue supporting a specific activity or range of activities over time.

Small_Group_Discussion_Group_3-3In the Workshop, CHLPI presenters invited attendees to envision policy advocacy as a three-fold process. First, advocates should assess potential policy goals for impact and attainability. Second, advocates can identify who will be both influential and supportive in accomplishing each policy goal. Third, advocates and their partners can collaborate to develop and implement an advocacy strategy for achieving each goal.

Following Garfield’s remarks, two Together on Diabetes™ grantees presented case studies on policy reform, featuring Dr. Richard Crespo of Marshall University and Manuela McDonough of the National Council of La Raza (NCLR).

Dr. Crespo, a professor of community health, focuses on diabetes health promotion in the Appalachian region. He spoke of creating diabetes coalitions and advocating for preventive health policy changes in local areas across the region. Notably, Dr. Crespo talked of some the coalitions’ success with farm-to-school programs and how the Food Law and Policy Clinic (FLPC) (a division of CHLPI) and its students had provided advocacy guidance throughout the process. The FLPC students provided the analysis that his advocacy teams brought to local policy-makers. These students empowered advocates, who then reached out to local decision-makers and improved outcomes for those with diabetes in many rural communities.

Manuela McDonough of NCLR spoke of policy advocacy for Latino health. McDonough noted that Latino communities have disproportionally high rates of diabetes. With a Together on Diabetes™ grant, NCLR has launched a Compañeros en Salud program, a peer support initiative to encourage diabetes-related goal setting and self-management of the chronic disease. Together with Peers for Progress and other partners, NCLR’s culturally-competent peer support program has reached over 4,000 clients in Chicago. To advance NCLR’s broader policy goal of achieving recognition and sustainable funding for peer supporters (also known as Community Health Workers) to be permanent members of health care teams, McDonough described how NCLR and Peers for Progress used the success of the Compañeros en Salud program to convene a broad coalition of experts in chronic disease, staff from relevant government agencies, and leaders of community health worker networks. This coalition drafted a Call to Action targeted at policymakers, asking them to support development of state-level recognition or certification regimes for Community Health Workers.

Small_Group_Discussion_Group_2Following the presentations, the attendees were broken into small groups to discuss policy advocacy. The small group breakout session was designed to help participants refine and prioritize policy goals and begin initial steps to establish policy action plans.

CHLPI faculty and students facilitated the small group conversations. Participants were asked to articulate a policy goal and help others to examine the attainability and impact of their policy goals. Importantly, CHLPI facilitators assisted discussants to frame their policy goals in terms of the benefit of the goal balanced with the organization’s available budget, technical capacity, and administrative experience. To improve potential effectiveness, CHLPI encouraged attendees to think of leveraging the resources of partners to create efficiencies in the policy advocacy process.

The small groups were the centerpiece of the Workshop. Small group participants worked to identify their organization’s policy goal while other group members contributed ideas to help sharpen and refine the goal under discussion. After each individual established a policy goal, the small group worked collectively to brainstorm strategies for implementing the goal, forming an action plan. This process included targeting prominent stakeholders, considering practical and financial barriers to change, and finding potential partnership opportunities.

Though the groups had distinct policy goals and faced region-specific challenges, common threads emerged. Groups noted the importance of engaging local communities and forging partnerships with other groups with similar interests. At the conclusion of discussion, the small groups presented their ideas to the attendees and reflected on the evolution of the group’s dialogue.

In advance of the Together on Diabetes™ Grantee Summit, the PATHS Workshop armed attendees with an overview of the policy advocacy process and tools they could use to accomplish their policy goals. As Sarah Downer noted in wrapping up the day, the attendees were “a natural coalition of partners” who could work together to transform ideas into actionable goals and identify concrete steps toward improving the lives of those with diabetes in communities across the country.

CHLPI is available to continue to support these organizations. As CHLPI clinical students, we appreciated the opportunity to get involved. We’re excited to move forward supporting these organizations in their important work to advance public health. As the Summit emphasized, we’re all in the fight against diabetes together!

Visit the PATHS website

To stay up to date on our work with PATHS and CHLPI’s other projects, follow us on Facebook and twitter.

The views reflected in this blog are those of the individual authors and do not necessarily represent those of the Center for Health Law & Policy Innovation or Harvard Law School. This blog is solely informational in nature, and not intended as a substitute for competent legal advice from a licensed and retained attorney in your state or country.

13 Million Americans at Risk of Losing Health Insurance in King v. Burwell

On Wednesday, March 4th, the Supreme Court begins deliberations in King v. Burwell, a legal case that threatens to strip away premium subsidies from two-thirds of states, thus putting low- to moderate-income Americans at risk of losing the health care coverage that was fought for through the Affordable Care Act.

At the core of CHLPI’s mission is expanding access to healthcare for traditionally underserved communities, particularly low-income individuals and families living with chronic medical conditions. The reforms of Affordable Care Act (ACA) made obtaining affordable, comprehensive health insurance a possibility for the first time for millions of Americans—including people with preexisting health problems. Federal tax subsidies are critical to lower-income Americans’ ability to purchase coverage on health insurance Marketplaces (a.k.a. “exchanges”). If these subsidies go away in Marketplaces run by the federal government, as the plaintiffs in King v. Burwell want, more than 13 million Americans in 37 states may lose their access to health insurance. CHLPI helped submit a friend of the court brief to the Supreme Court detailing the potential impact on people living with HIV and other chronic illnesses, and we will continue to closely monitor the case’s outcome.

A partner organization of CHLPI, Families USA launched a social media campaign, interactive video, and action center using the popular hashtag: #DontTakeMyCare. At the core of the campaign is a socially driven, interactive video that features deeply personal stories of people from across the country who are at risk of losing their subsidies, as well as a social media action center where supporters share and participate in a social conversation.  See the campaign in action.

Read more about the CHLPI King Amicus Brief about these issues filed in the U.S. Supreme Court.