The native health partners ensuring justice for people in Alaska


Alaska has the largest proportion of indigenous people of any US state. Its 229 tribes make up 18% of the total population, and many of them live in remote communities which are difficult to reach with public services.

Alaska Legal Services is the only state-wide provider of free civil legal assistance to low-income Alaskans. Its 12 offices and online and telephone support services help more than 7,000 Alaskans each year to resolve their legal problems, while its Partnering for Native Health program is a medical-legal partnership (MLP) that addresses health and justice problems simultaneously.

The COVID-19 pandemic has made it even harder to reach people living in remote communities, but at the same time demand for legal services has increased. In the latest of our Justice Champions of Change interviews, Alisa Jiménez asked Alaska Legal Services’ executive director Nikole Nelson how the organization has adapted to cope in such a taxing environment, and how the medical-legal partnership scheme has helped to mitigate the virus’s impacts.

Nikole Nelson (Photo: Alaska Legal Services)

Alisa: Could you tell me about the goals of Alaska Legal Services, and of the native health partnership in particular?

Nikole: Alaska Legal Services is a non-profit legal aid law firm. We’ve been operating in Alaska for over 50 years. Our core mission is to assure meaningful access to civil justice for all Alaskans, we have long recognized that oftentimes for Alaska Native people seeking access to justice is inherently tied to sovereignty and self-determination rights and so have been advocating with Alaska Native partners towards that end basically since we opened our doors.

The Partnering for Native Health program was a mutually beneficial opportunity for us to advance our work and for remote indigenous communities to secure better access to the justice system.

Alisa: How did it come about?

Nikole: About five years ago there was a convening on the Navajo nation in the lower 48 states [US states other than Alaska and Hawaii], where they had started the first ever medical-legal partnership in a US-based indigenous community. The convening explained what they were doing and that the MLP had really good outcomes for the Navajo population. And it made a lot of sense to me. The reasons why they had started their MLP reflected a lot of the struggles I knew of from my work in Alaska. They related to distance and geography and the limited infrastructure that is often found in indigenous communities due to the negative effects of colonialism.

When I came back to Alaska I wanted to convene our leaders to see if other people here thought this made sense as well. So I asked the folks from the National Center for Medical-Legal Partnerships and the folks from the Navajo nation’s project to come up and show our community what was happening there. We convened tribal healthcare leaders across the state and also state justice leaders from our supreme court and our court system.

Alisa: What do you mean by tribal healthcare?

Nikole: Alaska has a tribally-operated health care system that is operated by Alaska Native people themselves. While it is largely funded by the US federal government as part of its treaty obligations, the health care system itself is governed by Alaska Native people and has more flexibility that when health systems are run through the Bureau of Indian Affairs, which is a US government run program that operates healthcare systems for indigenous people in many other states. Alaska’s tribally-operated healthcare system takes a more holistic approach to health than I’ve seen in healthcare systems in general. Leadership from the tribally-operated healthcare system bought into the MLP idea right away, and they wanted to see if we could move forward to make this happen.

Photo: Alaska Legal Services

Alisa: Is it a good idea to combine justice and health care?

Nikole: At that time, we were part of the state court system’s access to justice task force, which was exploring how we could improve access to justice in general. And we decided to do some community resource mapping. We knew that there was a huge justice gap. At Alaska Legal Services we were doing a pretty good job of reaching remote communities — we help more than 170 communities every year, and 90% of those are off the road system. But we were also turning away one person for every one that came to our doors because of lack of capacity, because our funding isn’t adequate.

The mapping showed that lawyers are concentrated in the cities, and there are very few justice resources in remote communities. But what we also found out was that the strongest infrastructure in Alaska, which reaches all the way to the village level, is the tribal healthcare system. There’s a community health aide in nearly every single village.

And we learned from our health care partners that a patient’s health isn’t only determined by the care they receive. A large part of it is related to the social determinants of health. And when we looked at what the social determinants of health were, they were identical to many typical legal needs, such as lack of housing, homelessness, food insecurity, domestic violence or other types of abuse, and unstable income. The things that were most impacting people’s health were really those areas that legal aid lawyers specialize in trying to address. There was obvious overlap.

Until that point our model had been to continue to expand our reach through trying to build out our legal infrastructure, but following the mapping and with our new understanding of medical-legal partnerships we realized that there was an opportunity to partner with the health system and share some of their infrastructure to help us deliver our services and expand our reach. This would be beneficial to our healthcare partners as they would gain capacity to address social determinants of health.

When I explain to people the legal counterpart to public health that we’re building, I tell them we’re trying to provide a legal inoculation for people. So if everybody knows their rights and they know they’re going to be enforced, it’s less likely that somebody’s going to cross that boundary. But it requires getting a legal inoculation — the general population has to have a basic understanding of their rights, and a reasonable chance of enforcing them.

Photo: Alaska Legal Services

Alisa: Who do you partner with?

Nikole: Our main partners are the Alaska Native Tribal Health Consortium, and Alaska Pacific University. They’re wonderful partners, and we have really learned so much from them and they have really expanded and changed our thinking so much. The partnership has been very beneficial for us.

Alisa: What kind of things did you learn?

Nikole: Our health care partners led us to rethink how to redesign our whole civil legal aid delivery system. They were so far ahead of ahead of us in so many things. For example, on stratifying practitioners. It isn’t really possible to have a doctor in every village or a specialist of every type in a hub community, but there’s maybe a nurse practitioner or a health aide. There’s a whole range of health care providers that are qualified to provide a range of services — you don’t need a doctor to give an inoculation. It made us think about how we could do the same sort of stratification in the legal system. Do we really need a lawyer to help somebody fill out a power of attorney form? Are there things that we could train people who didn’t need to go to law school to do competently and effectively?

The next thing we learned has to do with the fact that there’s no law school here. For the 50 years we’ve been operating, we’ve relied on importing people from outside Alaska, predominantly white people, to serve communities that largely are not white. There aren’t as many indigenous lawyers or Alaskan native lawyers as we might like. The healthcare system had faced the same dilemma; it relies a lot on importing professional from outside Alaska for short stints of time. So over 20 years ago they started developing systems — a community health aide program, that overtime has expanded to include dental health therapists and behavioral health aides — where they recruit people from local communities and provide training, including through distance learning, as a way to develop a more culturally appropriate and community based workforce. The aides are then able to serve their communities, and have support from doctors or higher-level practitioners as needed. And we thought we should be doing that with legal aid too.

Alisa: How did you implement these lessons?

Nikole: We’ve been partnering with distance-learning professionals at the Alaska Native Tribal Health Consortium and with Alaska Pacific University, a tribally-affiliated university, to develop a curriculum that will help train advocates, who aren’t lawyers, and who are culturally appropriate and community based.

Photo: Alaska Legal Services

But we realized that in a lot of the very small remote villages there might not be enough work to keep a legal advocate fully employed. So we thought about cross-training community health aides to screen and surface unmet legal needs and help to resolve them too. They could become cross-trained health and legal advocates. That could be a job, at some point, that somebody has within a village.

Alisa: And then came the COVID-19 pandemic. Has Alaska been badly affected?

Nikole: There haven’t been as many COVID cases as in other regions, but our economy completely tanked. We already started out with the highest unemployment rate in the nation. A lot of our economy is based on seasonal tourism and commercial fishing during the summer, and a lot of that went by the wayside.

Alisa: Have you seen certain types of justice problems become more prevalent as a result of COVID?

Nikole: Yes, in three main areas. Firstly, housing. People are having problems with housing, especially landlord-tenant issues, and they’re confused about what the rules are because there have been multiple changes to these laws.

Secondly, unemployment. There was a big need around that, and employment wasn’t an area of specialty for us before this so we had to learn about the unemployment law system when it comes to benefits and what options are available and to try to get them information out to the community.

And thirdly, a lot of our advocacy relates to domestic violence issues, and that has become really challenging too because of social distancing requirements for the limited shelter space. Alaska has some of the highest rates of domestic violence in the nation and a lot of our remote communities don’t have local police or courts, so it’s very isolating, and it’s also difficult to escape someone who’s been abusive to you.

Alisa: How have you responded to these problems?

Nikole: On domestic violence, it’s been about making sure that people know that there are options available even though the shelters are at reduced capacity, and the courts have limited operations. This has been perhaps the most difficult problem to respond to. We’ve had several domestic violence deaths occur during the pandemic.

On unemployment, we had to make sure we could get information widely distributed to our remote regions about pandemic aid, and about the differences between the various forms of relief and stimulus payments that were available.

On housing we’ve done a lot of outreach on social media. A lot of people use Facebook here, so we’re doing Facebook live sessions, and we bought Facebook ads to try to target specific communities to get information out to people. There is confusion about what is and isn’t allowed and what you do if the courts are closed. The confusion is on both sides, from landlords and tenants.

Alisa: Could you tell me what success looks like for like someone that you’re working with?

Nikole: One of my favorite medical-legal partnership cases was of an elder in Juneau. He needed to be flown to Anchorage to receive care at the tribal-operated hospital here. When he arrived, he was unconscious, but the staff saw that he had an eviction notice among his papers. Upon finding this, they sprang into action and reached out to the MLP person at the hospital. She found that the elder had already missed his eviction date, meaning he had defaulted. While working with the elder to get the eviction set aside, she ended up talking with the landlord and telling him what had happened and that this poor man was going to be discharged into homelessness. She ended up not only persuading the landlord to undo the eviction but he felt so bad that he agreed to pick up the elder from the airport, bring him home, and move him to a different apartment. The new apartment was within the same complex and was even better suited for the disabling conditions that he had! So that’s what success looks like to me, many people working together to come to a result that everyone can feel good about.

Alisa: Finally, what do you think justice systems can learn from indigenous communities?

Nikole: The pandemic is a jolt to the system, and I think we should take this time to rethink everything. We need to start having conversations about what outcomes we want, and what justice actually means. We have this really complicated system for achieving justice, and the outcomes aren’t great. In the criminal system we are overly incarcerating people of color and poor people. And in the civil system those same groups of people can’t access justice at all.

I think we would do well to look at examples of a more restorative approach to justice, and this is where tribal systems can be instructive. Our current systems are designed to produce justice like it’s an object, a paper that you can deliver to somebody, but really justice is this feeling that you get by going through the process. And we should spend some time thinking about how people get to that feeling.

In my experience, people feel justice has been achieved when they have an opportunity to be heard, when the dispute has been healed, when there’s some accountability, and when there’s a pathway that leads to a future where that same rift doesn’t happen again. The Western system of justice isn’t really designed to facilitate that process; it mostly just assigns blame. It doesn’t take into account that people have to go back and have a future relationship with each other. In many tribal justice systems, there is an emphasis on community building and healing and restoring harmony to people who were having some sort of dispute, rather than necessarily assigning blame. I definitely think that is something we would do well to think about.

To read more justice Champions of Change interviews, visit: https://www.justice.sdg16.plus/champions-of-change