Institutions nationwide are piloting new ways to take care of patients’ needs beyond the hospital bed. That task took on added urgency when Republicans on the Joint Economic Committee released the results of their investigation into social networks among the elderly earlier this year. The analysis: social networks are declining and America is going to pay for it – probably in higher healthcare costs.
 
“[A]n increasingly inadequate level of informal care . . . would necessitate a greater amount of institutional care outside the home and away from loved ones, reducing, for many, their quality of life,” the Committee wrote. “[I]nstitutional care often entails burdensome expenses,” including individuals spending down their assets and the public paying for costly nursing home care. 
 
For many seniors, informal networks of friends and family help them perform household chores, organize their finances, and navigate their medical appointments. These informal care networks are vital to addressing, as the CDC put it, “conditions in the environments in which people live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks,” or “social determinants of health.” According to scholars at Yale Law School’s Solomon Center, “25 percent of individual health is determined by genetics, medical care, and health behaviors, while 75 percent of health is determined by social and environmental factors.” 

Some states, such as North Carolina, and the federal government, through the Medicare Innovation Lab’s Accountable Health Communities Model, are funding demonstration projects that refer patients to local social services organizations. For example, Yale New Haven Hospital in Connecticut launched a program last April to seamlessly integrate screening for social determinants of health into regular emergency room and primary care visits, though Medicare rules prohibit the program from directly providing social services.
 
To date, however, many such programs have left out a substantial and often overlooked factor that affects health outcomes: patients’ legal needs. After all, seniors who come home from the hospital to unstable housing, unpaid bills, and unresolved Social Security claims will have trouble recovering and getting back to their lives. More than 300 charity-supported medical-legal partnerships (MLPs) have stepped into this breach.
 
MLPs are partnerships between healthcare and legal services providers. Doctors and hospitals refer low-income patients with unmet legal needs to attorneys, who are often embedded on site and see patients at the same time their doctors do. MLPs serve immigrants, formerly incarcerated individuals, veterans, and numerous other at-risk groups, including the elderly. Critically, these populations often do not realize they have legal needs or trust lawyers to assist them. Pairing lawyers with doctors in settings of confidentiality and trust gives these populations access to critical support.
 
Elder care and end-of-life MLPs can help address the challenges that shrinking social networks pose for seniors. The growing number of MLPs focusing on the elderly assist clients in ways which both complement and replace services and supports that social networks may, in the past, have provided.

For example, a major issue among patients at or near the end of life is selecting someone to help make their healthcare and financial decisions. The Palliative Care MLP in New Haven, CT, sends law students - under the supervision of licensed attorneys and working alongside the New Haven Legal Assistance Association – to meet with low-income cancer patients based on referrals from Yale-New Haven Hospital’s social work team. The MLP helps patients draft documents, called advanced planning documents or directives, that appoint a trusted relative or friend to make major financial decisions or life-and-death healthcare choices.
 
These services not only save money – a systematic review found facilitating advanced care planning saves thousands of dollars per patient in healthcare costs annually – but they also support the mission of palliative care itself by easing patient stress at the end of life.
 
Distance and a lack of social supports, as the Joint Economic Committee’s report points out, take the difficult situation that elderly patients and their families face and make it worse. How can families pay their loved ones’ bills or monitor their bank accounts? How can patients obtain food or housing, especially if they lack transportation and support to apply for public benefits?
 
The MLP for Seniors Clinic at the University of California-Hastings helps elderly patients apply for federal and state public benefits. University of Florida Health works with Three Rivers Legal Services in northern Florida to help seniors address issues with housing, employment, public benefits, and other legal matters. Through both organizations, patients who only leave home for medical visits can get help applying for public benefits while they receive medical care. And, by obtaining stable housing, food stamps, and other social services, seniors can afford to stay in their own home when moving in with a nearby relative – or having a relative check on them regularly – is not an option.
 
Second, MLPs can help families bridge distances. When Yale’s Palliative Care MLP helps patients spell out formal relationships in legal documents, family members can more easily assist far away relatives with healthcare and financial tasks. For example, seniors can identify a healthcare decision-maker before a crisis hits. Relatives and friends across the country can get access to online banking and bill pay accounts.
 
According to an AARP survey, “[o]nly 10 percent of older adults with no social needs were in fair or poor health . . .  , compared to 80 percent of those experiencing six or more [unmet] social needs.” MLPs offer a low-cost, proven model to supplement the social services families provide. As America confronts an aging population with less community support, caring for the whole patient will become more and more important. ​

Joseph Liss is a member of the Class of 2020 and a Student Fellow at the Solomon Center for Health Law and Policy at Yale Law School. He graduated with a Master of Public Policy from the Frank Batten School of Leadership and Public Policy at the University of Virginia in 2015, where he served as Senior Online Editor of the Virginia Policy Review.

The highlight of Black History Month took place when former President Barack Obama, along with basketball star Steph Curry, took center stage in Oakland, California to address issues facing young men of color. Obama and Curry were not there to talk about how to change federal policy. Instead, they discussed tangible ways in which young black men can facilitate stronger and safer communities.

The town hall event, sponsored by Obama’s “My Brother’s Keeper Initiative,” stressed the values of community mentorship and personal responsibility. The topics raised were wide-ranging. Among them were ways to support young men without fathers, how to reject toxic masculinity, and the importance of embracing monogamy.

Obama spoke candidly about how communities need to raise the level of expectation for how young black men should act. Emphasizing that “real” men do not show their manhood by disrespecting others, or by putting women down, he tried to counteract some of the pernicious elements of culture that are found in some black communities. It was a timely reminder that a strong moral compass makes a difference in life.

He also talked about the value of education. Sitting next to one of the NBA’s greatest players, he told young men they had a better chance of being a lawyer or a doctor than a professional basketball player. In my mind, these nuggets of wisdom Obama imparted were not controversial. But unsurprisingly, some people were upset with him for raising these issues.

Obama’s advice to black youngsters was a deviation from the “victimhood” narrative that is widely accepted among many left-leaning circles as the only constructive way to talk about race.

Some columnists openly criticized the former President and almost all Democratic Presidential candidates offered no praise. (Only Kamala Harris offered a tweet in support.) The lack of praise for Obama’s actions is disheartening.

It’s troubling that more than 50 years after the Civil Rights Movement, there is no space in our political discourse for equal attention to the value of personal responsibility that we give to deconstructing institutional barriers.
 
One columnist in particular, Derecka Purnell, published a piece entitled “Why Does Obama Scold Black Boys?” The fiery piece characterizes Obama’s message as patronizing and on par with how “conservatives depict black people.”

In her defense of her argument, she cites Cornell West’s book “Race Matters,” which says:

Purnell does have a point. (Some, not all) conservatives have a history of using the rhetoric of personal responsibility as a weapon against blacks in order to advocate against particular policy changes.

But just because some have used it to inhibit legislative action does not mean the underlying message has no substance. Telling young black men to respect women, be role models in their community, and prioritize educational achievements over athletics are not partisan statements. In fact, the encouragement of a strong moral compass and personal accountability is within the African American tradition.

Martin Luther King Jr. advocated for the very same principles that Obama talked about.

In a 1953 sermon, King preached that:

​But he also gives equal weight to how institutional barriers shape our lives. To capture his message, I quote him at length:

​It goes without saying that when King gave this speech in 1953, racial equality was abysmal at best.

But in spite of that, King understood the need to give equal weight to personal responsibility. He understood that African Americans were not helpless victims unable to take control over certain aspects of their lives. As he moved further into his career, he would not abandon this belief. King and other black leaders at the time spoke-openly about the importance for more responsible behavior in black communities.

It’s unlikely that anyone at the time believed that King didn’t understand the impact of structural inequities. So why do some not give Obama the benefit of the doubt?

I think it’s because talking about personal responsibility changes the conversation that one side has built a narrative around. Purnell further writes in her piece:

I disagree. Programs like MBK give black men a sense of moral agency that can make them into the best versions of themselves, in a world that doesn’t always hand out a second chance.

And if we were serious about solving racial issues, we would be willing to engage seriously with both sides of this issue.

From a policy standpoint, the myopic focus on dismantling “systems” is incomplete. It’s a mental shortcut that posits the idea that the only way for the improvement of black life is through some governmental intervention and policy change.

The critics will argue, as Purnell does, that social and legislative change are what is required to bring about the justice we deserve.

For the record, I agree — sort of.

I want greater access to healthcare, more funding for education, and an equitable criminal justice system. We need a reorientation of our public policy with greater magnitude and depth than we’ve ever seen before.

But that’s not all I, nor we, should want.

Is it really possible that by authorizing this social program, appropriating more money to some agency, or increasing federal oversight will suddenly deliver the kind of justice we want to see?

I don’t think so. It’s a seductive argument but a weak one that gives no weight to answering moral questions. Instead, a more comprehensive approach in which we equally address internal behaviors and external systems that perpetuate inequality, is a better path forward.

Obama is a little late to the party. But since leaving office, his devotion to ensuring black men take personal steps to bettering themselves is worthy of all our praise. And through his actions, he is re-claiming the personal responsibility narrative from those who historically employed it for partisan gain. Unlike some conservatives in the past who pejoratively talked about “personal responsibility” without any real follow up, Obama is dedicating considerable energy to showing how black men can actually better themselves and their community.

Across generations, black leaders like Booker T. Washington, Marcus Garvey, and Martin Luther King Jr., all believed that living a moral life and taking responsibility for your own actions are essential to the black identity. Obama’s revival of the topic, in a responsible and focused manner, reminds us of this tradition. And that is why it was the highlight of Black History Month.

If you still disagree with me, I ask you to ponder the following questions: Is there anything that Obama said in that town hall that you would not tell your own son?
 
And if you would tell your own children to do so, why do we not unanimously praise Obama when he does it?

If the folks on both sides of this divide would equally embrace the nuances in these issues, perhaps we would see a healthier discourse, more effective public policy and a better America. But doing so requires that we leave our ideological and political motivations at the door.

Let us not forget: black history is American history, black progress is American progress, and black struggles are American struggles. Therefore, the impetus is on all of us — regardless of party, race, or ideology — to engage with these issues in holistic and constructive ways. The stakes are too high, the promises of equality are long overdue, and the Americans whose lives we are trying to improve deserve better.

Corruption is everywhere. According to Transparency International's 2018 Corruption Perception Index report, about two-thirds of countries in the world have very high levels of corruption. Democratic elections are supposed to be a means of granting citizens the voice to penalize corrupt leaders that are benefiting at the expense of the electorate. However, from my experience in my home country, Zimbabwe, and the results in many other developing countries, elections are frequently failing to hold leaders accountable. Elections strengthen dictatorial rule and further corruption by the ruling party under the guise of legitimized support by the voters. The failure to control corruption and lack of transparent administration of elections are a growing threat to democracy.
 
Allegations of election fraud are a common feature of the electoral cycle for most African elections. International observers swarm a country in an attempt to ensure that the incumbent government administers free and fair elections. However, this monitoring does not seem to be a significant deterrent for election fraud given how frequently opposition leaders call elections into question.  Just this past month, the elections in the Democratic Republic of Congo (DRC) and Nigeria were initially postponed, raising concerns of corruption and rigging.
 
Election fraud manifests itself across the world in different ways. Several African leaders in power have been accused of employing some of the following tactics to maintain power:

• Turnout and vote buying: paying people to show up to the polls and to cast ballots in a candidate's favor.
• Ballot rigging: tampering with voting machines, ballot papers, and/or ballot boxes.
  
• Inaccurate result announcement: blatantly choosing to misrepresent the number of votes.
• Coercion: using violence to intimidate voters into participating or avoiding the polls.

Vote and turnout buying tactics are particularly effective in areas with vulnerable poor populations as people get swayed easily through the provision of income or goods that can sustain their livelihoods. The negative involvement of the media through pro-ruling party propaganda, the use of violence, and the abuse of the courts are some key features of the most recent contested elections.

In many countries, media has become a tool for creating more profound polarization around election time. With the rise of the term “fake news,” media is viewed as a less objective source of information for voters. While social media has become a great symbol of democratic expression, these outlets have also been utilized to foster electoral violence and perpetuate propaganda. In developing countries where digitalization is still growing, the government has significant power over the media such that most of the news and advertisements often have a substantial skew in favor of incumbent leaders. The governments in many developing countries also have considerable abilities to censor online communications, as is claimed to have been the primary issue with the Cambodian election last year. Massive crackdowns on social media platforms like WhatsApp have been a key strategy used by incumbent parties to control information disseminated among citizens in developing countries.

The Nigerian opposition leader, Atiku Abubakar, who denounced the results of the February 23rd election, cited violence as one of the reasons he deemed the electoral process to have been illegitimate. In many elections, opposition leaders and their supporters are suppressed violently through jailing, torture, and even killings allegedly perpetrated by the ruling party. Election sabotage strategies like these lead to unequal public campaign opportunities. When voters’ confidence in the electoral process is undermined, this either leads to violence or voter apathy. In Africa, where youth unemployment is rampant, it is worth noting that politicians often take full advantage of the frustrations of young voters to incite violence. Violence can also be perpetrated by government military forces whose more prominent presence during electoral periods is used more as an intimidation tactic rather than for the protection of citizens. Over the past year, military involvement was a key theme of the elections in Pakistan, Zimbabwe, Bangladesh, Madagascar, and the DRC. Malawi, which is set to have its elections in May, has already begun experiencing violence.

​When there is an election dispute, most countries have legal processes in place that is meant to provide an impartial judgment on the validity of the results. Nigeria's Abubakar has chosen to take his complaint to the courts. Several other elections have ended in a similar fashion, but it is unclear whether there are sufficient checks and balances between the courts and the ruling government in most developing countries to grant due process to the candidates contesting the results. The Kenyan court's decision to force a rerun election in 2017 was one of the only recent occasions when a court has ruled against an incumbent president. Even when election observers highlight apparent election irregularities, such international pressures have not stopped inauguration ceremonies from continuing, as was the case in Zimbabwe last year and in the DRC this January. Instead, opposition leaders and their supporters are more likely to be prosecuted during or after the electoral cycle. The perpetuation of such treatment undermines democratic civic participation and may even reduce the number of individuals willing to challenge incumbents. Meanwhile, ruling leaders get away with their use of power to bend constitutional laws in their favor in future elections.

The problems with election fraud have not only affected developing countries. The President of the United States, Donald Trump, has received his share of allegations due to the questionable involvement of Russia in the 2016 election. State and local elections in the United States have also been scrutinized primarily for voter suppression. Gerrymandering, or the redrawing of district borders in favor of the incumbent party’s voter interests, is a frequent topic of conversation around election fraud in the United States.

While institutional corruption and election fraud issues may not affect the US state and federal elections in the same detrimental manner as it does in African elections, such negative trends in electoral accountability are likely to continue raising questions about the legitimacy of democratic electoral systems. It is essential for countries to make more significant efforts to strengthen governance by implementing reforms that improve the role of legal and political systems in ensuring the legitimacy of elections.

Failure to come up with innovative solutions to prevent electoral fraud will continue to cause the loss of faith in elections and to threaten the future of democracy, especially in developing nations.