The Political Determinants of Health: A Global Panacea for Health Inequities
The Political Determinants of Health: A Global Panacea for Health Inequities
- Daniel E. Dawes, Daniel E. DawesSatcher Health Leadership Institute, Morehouse School of Medicine
- Christian M. AmadorChristian M. AmadorSatcher Health Leadership Institute, Morehouse School of Medicine
- and Nelson J. DunlapNelson J. DunlapSatcher Health Leadership Institute, Morehouse School of Medicine
The political determinants of health create the structural conditions and the social drivers—including poor environmental conditions, inadequate transportation, unsafe neighborhoods, poor and unstable housing, and lack of healthy food options—that affect all dynamics involved in health. Globally, recurring examples of the role that these political determinants—through government action or inaction, and policy—are playing in health outcomes and life expectancy, particularly in under-resourced communities, can be observed currently as well as historically. Most notably, the political determinants of health are more than merely separate and distinct from social determinants of health: they serve as the instigators of the social determinants of health with which many people are already well acquainted. They involve the systematic process of structuring relationships, distributing resources, and administering power, operating simultaneously in ways that mutually reinforce or influence one another to shape opportunities that either advance health equity or exacerbate health inequities. Focusing on the political determinants of health homes in on the fundamental causes that give rise to, sustain, and exacerbate the social determinants of health that create and worsen the persistent and devastating health inequities that are observed, experienced, researched, and reported. By employing both a theoretical and practical lens to the amelioration of health inequities that continue to pervade communities across the globe, the article contextualizes many of the historic harms that have occurred throughout history, providing a unique perspective on the current state of affairs, and offering a tangible path forward toward a more equitable future. Furthermore, consideration of this new framework at all levels of government as it relates to improving health outcomes for any nation is imperative in order to eliminate existential threats for any and all populations.
- Global Health
- Public Health Policy and Governance
Globally, progress has been made to reduce racial and ethnic health inequities; address unjustified discrimination in health care access, quality, and value; and expand the conversation about their root causes. Today, the social determinants of health are widely recognized as contributing—and even determining—as much, and often even more, to the health and well-being of individuals than medical care and genetics. Additionally, as greater attention is paid to the social determinants of health, the deleterious consequences of racism and racial bias simply cannot be—and increasingly are no longer being—ignored. However, for elimination of the health inequities that sit downstream to occur, addressing the upstream factors must take place first, with a focus on the political determinants of health that provide the momentum and currents that have created and sustained the social determinants of health, which in turn have fueled and resulted in the disproportionalities in health, life expectancy, and quality of life. Opportunistic in nature, these socioecological disproportionalities have created synergies with biological factors that were observed during the COVID-19 pandemic leading to worst-case scenarios for many low- and middle-income countries globally, syndemic situations with both communicable and noncommunicable diseases (Yadav et al., 2020).
One such example lies within the country of India, which had battled a tuberculosis epidemic for years and found itself crippled when the COVID-19 pandemic struck. This disrupted efforts to contain and treat tuberculosis due to the need to shift resources to address the COVID-19 virus or arguably because it was unequipped to handle the two scenarios simultaneously. In a country that suffers no shortage of risk factors for tuberculosis including air pollution, smoking, inadequate treatment of infection, HIV, overcrowded living conditions, and an increased burden of diabetes that can lead to severe multi-organ tuberculosis infection, India also had to deal with suboptimal governmental policies creating a precarious situation for the country’s public health. Surveillance still relied on a dated paper-based system for recording and reporting. There was a lack of prior planning to ensure uninterrupted tuberculosis drug supply, and disruption in the transportation of patient samples, tuberculosis drugs, and lab supplies, which have collectively contributed to the worsening of tuberculosis in the country during the COVID-19 pandemic (Bardhan et al., 2021). Like India, there are countless other stories to recite across the globe in which the COVID-19 pandemic has opportunistically disrupted a country’s essential public health services, incapacitating already disadvantaged groups even further.
The concept of political determinants of health is introduced to inform thinking on how the structural conditions in which people are born, live, and die are developed over time; how political determinants of health create the milieu—such as environmental conditions, housing security, transportation access, and food options—that determine all aspects of health and life; and how they are the fundamental creators, perpetuators, and drivers of health inequities. By then equipping the reader with an application of the political determinants of health, a simple snapshot of a complex and highly reticulated concept is presented. This article is not designed to be all encompassing but rather aims to highlight key considerations and concepts of a complex topic, while offering a new framework for readers to use as they consider the impact of politics and policies locally, nationally, and internationally over time on the health, well-being, and lives of their respective population groups.
Cultivating and Advancing Health Equity: Social Determinants of Health
A society cannot expect to create change and cultivate a more equitable one without first looking at the structures in which people are born or placed. How can a society mobilize and advocate with disadvantaged, marginalized, and under-resourced populations and their communities to fight for equitable health care and resources? To truly move the needle of health equity forward, it is paramount to first acknowledge and address the systemic barriers that exist and persist. The reality is that in every country of the world, that nation’s health is not an organic outcome. It is not a coincidence that certain groups of people experience higher premature death rates than others. It is not a fluke that some groups experience poverty for generations, blocked from attaining their health potential. The depths of the problem may go unseen up until the point of exploration, a search for and examination of their root causes and distribution. This includes the social determinants of health, which are defined by the World Health Organization (WHO) (2022a) as follows:
The social determinants of health are the conditions in which people are born, grow, live, work and age, and also includes the health system. These circumstances are shaped by the distribution of money, power and resources at global, national and local levels, which are themselves influenced by policy choices. The social determinants of health are mostly responsible for health inequities—the unfair and avoidable differences in health status seen within and between countries.
By understanding these circumstances, the root causes of disparities in care for vulnerable populations as well as strategies to address them can begin to be identified. Characteristics such as race or ethnicity, religion, socioeconomic status (SES), female gender, age, mental health, disability, sexual orientation or gender identity, and geographic location, among others, have historically been linked to exclusion or discrimination and are known to influence health status (Dawes, 2016). Over time, efforts to understand the epidemiology of health outcomes, conditions, contexts, and disparities have begun to provide important information needed to identify the populations that are disproportionately affected by systemic racism, health inequities, and social and environmental disparities.
Several existing publications highlight the role that structural and systemic racism play as a cause of all health and social disparities (Benjamins et al., 2021; Smedley et al., 2003; Williams et al., 2019). The COVID-19 pandemic and the disproportionate and deleterious impact that it has and continues to have on minoritized and marginalized communities globally uncovered even further how deeply racism is embedded within the social determinants of health. The COVID-19 pandemic, arguably a syndemic, has impacted everyday life in most countries in many ways, but none more so than the prioritization of health care. In the United States, for example, African American, Native American, Latin(o/a/x), and Pacific Islander families experienced disparities in everything from fatalities due to the virus to educational inequalities for children as schools shifted to remote learning. From the pandemic, it was learned that people of color are at an increased risk for serious illness if they contract COVID-19, due to higher rates of underlying health conditions, as compared to Whites. People of color are more likely to be uninsured and to lack a usual source of care, which is an impediment to accessing COVID-19 testing and treatment services. People of color are more likely to work in the service industries such as hospitality and retail that may put them at risk for loss of income during a pandemic. People of color are more likely to live in housing situations, such as multigenerational families or low-income and public housing, that make it difficult to practice social distancing or self-isolate. People of color often work in jobs that are not amenable to virtual or remote work and depend on public transportation, putting them at higher risk for COVID-19 exposure. As a result of this environment of socioeconomic, political, and cultural adversity, the psychosocial stress inflicted upon people of color, specifically Blacks in America, has contributed to the troubling metaphor developed by Dr. Arline Geronimus known as the “weathering” hypothesis, which results in the acceleration of the overall biological and aging process for these individuals (Forrester et al., 2019; Geronimus et al., 2006).
A unifying, yet irrefutable, fact is that health inequities, and the political determinants of health that propagate them, are a global phenomenon. Across developed and developing countries alike, recurring examples of the role that policy and legal decisions are playing in the downstream health outcomes of individuals, particularly in under-resourced communities, have been observed. Take, for example, President Jair Bolsonaro of Brazil. As president of a country with one of the highest COVID-19 mortality rates in the world, President Bolsonaro’s decision to publicly denounce the COVID-19 vaccinations has and most likely will continue to have significant impacts on the citizens of his country and their health outcomes (WHO, 2022a). In October of 2021, President Bolsonaro made his stance clear by stating he had “decided not to have it anymore” and further clarifying that while he was not anti-vaccination, he did oppose what he called the vaccine-buying “frenzy” (Phillips, 2021). With over 620,000 deaths in Brazil, as of this writing, a conscientious decision by the political leader of the country to not support efforts to purchase vaccinations is a stark reminder that the decisions of those in power have existential effects on those governed therein.
Yet, the decisions of a vaccine-skeptical leader in South America are not the full story of the global impact and import of the political determinants of health. As a matter of fact, this example does not even begin to highlight the leveraged role that the political determinants of health currently play in the race to emerge on the other side of the COVID-19 syndemic. Consider, as an illustration of such, the inequitable distribution of COVID-19 vaccinations across the global community and the lingering effects of such. Or, as Tedros Adhanom Ghebreyesus, director-general of the World Health Organization, stated in a more succinct fashion, “the unequal distribution of vaccines is not only a moral outrage, but economically and epidemiologically self-defeating” (WHO, 2021a). What this means in practicality, as the WHO stated, is that “COVID-19 vaccine inequity will have a lasting and profound impact on socio-economic recovery in low- and lower-middle income countries without urgent action to boost supply and assure equitable access for every country, including through dose sharing” (WHO, 2021b). While this dire warning was conveyed by the WHO in July of 2021, evidence indicates that efforts to stem the tide of inequitable distribution have by and large proven insufficient.
According to the WHO’s Coronavirus (COVID-19) Dashboard, many regions of Africa still significantly trail other parts of the global community in the administration of COVID-19 vaccinations (WHO, 2022b). What this highlights is that decisions made at the highest levels of one country can have significant downstream effects on the respective citizens of another country, resulting in the collective exacerbation of health inequities in the broader global community. To put an even finer point on this reality, look no further than the global health worker shortage. The New York Times highlighted the issue during the pandemic, by stating that
the urgency and strong pull from high-income nations—including countries like Germany and Finland, which had not previously recruited health workers from abroad—has upended migration patterns and raised new questions about the ethics of recruitment from countries with weak health systems during a pandemic (Nolen, 2022).
While this trend of mobilizing foreign-trained doctors and nurses in response to COVID-19 will undoubtedly continue to benefit globally wealthy countries, such as those in the Organization for Economic Cooperation and Development (OECD), the draw on human capital will also continue to leave the under-resourced members of the global community further and further behind (OECD, 2020). The fact that regions of the globe that lag in vaccination administration, due in large part to policy decisions made by the globally affluent, must also simultaneously contend with the reduction of their clinical workforce due to the recruitment by those very same globally affluent decision makers, is emblematic of the impact of the political determinants of health beyond borders.
Yet, the impact of the political determinants of health existed before the onset of COVID-19 and extends beyond such as well. Consider, for example, Australia and the “stolen generation.” In the early 1900s, the Australian government adopted a child removal policy birthed from the Aboriginal Protection Act of 1869 mainly geared at the removal of mixed-race aboriginal children from their families, under the false pretense that “full blood” aboriginal people would eventually become extinct after a sharp population decline from European colonization of the region (Manne, 2008). This adoption of an institutionalized apartheid led by British-Australian public servant Auber Octavius Neville, named chief protector of Aborigines, was an attempt by the Australian government to assimilate the indigenous aborigine into society and marry them with people of lighter skin tones over successive generations to “breed out the color” (Read, 1981). The result of this policy left the “stolen generation” with a wide range of adverse health outcomes: poor physical and mental health, including high incidences of substance use, anxiety, depression, PTSD, suicide, absenteeism in school, and poverty (Allam, 2019).
Peering even further back in the annals of time, in the Central American country of Honduras, colonialism by the Spaniards also brought about a similar story and fate to the region. Once a thriving population of a complex mixture of indigenous populations and linguistics, the country is now reduced to a fraction with only about 9% of the total population self-identifying as members of the indigenous community per the country’s latest census (Quartucci, 2021). The Lenca people, who are now the largest indigenous group in the country, mainly live in remote hard-to-reach mountainous areas, presumably as a survival tactic resulting from historical oppression into vassalage or elimination of them all together, by the Spanish settlers in the 1500s; they lack basic services such as running water and latrines, roads, and transportation (Quartucci, 2021). When discussing health and the environment, in particular the role of water and sanitation, the Pan American Health Organization (PAHO) (1997, p. 14) reports that “there is a tendency to characterize indigenous populations as being similar to poor and marginal urban populations. However, there is little official data on the coverage and quality of water supply and sanitation services in these populations.”. Several organizations also published the following challenges faced by indigenous populations: fluctuating maternal mortality rates (190 – 255 per 100 thousand births) and non-culturally appropriate care (di Fabio & Almeda, 2006, pp. 198-199); a decreased life expectancy for both men and women of up to 20 years high incidence of poverty, malnutrition and infectious diseases (United Nations, n.d.) , and high incidences of parasitic infections (PAHO, n.d.) all contributing to overall poor quality of life for these populations
. Adding to the neglect, the Lenca have also been subject to human rights abuses. In one of the most high-profile cases, at least three instances were reported where indigenous activists were murdered for defending against the building of hydroelectric dams on their lands after the Honduran government passed the Law on the Promotion of Public/Private Alliances in 2010, which privatized 47 rivers in the country (Global Witness, 2017; Minority Rights Group International, 2018; World Bank Group, 2021). In this instance, not only did policy propagate the mistreatment of an already vulnerable population on the verge of extinction but its inaction to properly investigate the occurrences is also a passive stance against the situation.
Yet, notwithstanding these historical, and to a certain extent demoralizing, examples of the role of the political determinants of health, there remain even more contemporary moments in history to point to. Consider the multigenerational harm inflicted by the policies of apartheid that were implemented in South Africa. As an in-depth, and still prescient, special report from the New England Journal of Medicine puts it,
in the [decades] since South Africa underwent a peaceful transition from apartheid to a constitutional democracy, considerable social progress has been made toward reversing the discriminatory practices that pervaded all aspects of life before 1994. Yet, the health and well-being of most South Africans remain plagued by a relentless burden of infectious and noncommunicable diseases, persisting social disparities, and inadequate human resources to provide care for a growing population with a rising tide of refugees and economic migrants (Mayosi & Benatar, 2014, p. 1344).
The National Party, which came to power in South Africa in 1948, made apartheid a state policy and espoused the discriminatory ideology that people of different racial origins could not live together in equality and harmony, often failing to look at the downstream effect this state policy continues to have on health outcomes today (Reddy, 2021).
Taking a more expansive point of view, beyond the scope of nation-state borders, one can even look toward regional policy decisions to see the far-reaching impact of the political determinants of health. Take, for example, the effect that “Brexit” has had on health and health care outside of the United Kingdom. While acknowledging that the principal effects of Brexit on health and health care fall within the United Kingdom, as the Journal of Health Politics, Policy, and Law so effectively demonstrates, it is worthwhile to also consider the external effects of Brexit for health and health care or what has been coined the “Brexternalities” (Hervey et al., 2021). Consider the massive disruption that Brexit has had on health infrastructure. For example, “U.K.-based companies, which supply products across the EU, need to shift regulatory interactions to other member states, so as to secure continued access to the EU’s internal market” (Hervey et. al, 2021, p. 185). Or even further, the reality that “pharmaceuticals batch-testing facilities needed to be transferred from the U.K. to the EU” (Hervey et al., 2021, p. 186). These are but a few of the reverberating ramifications that have been felt as a result of the upstream decisions to Brexit—all of which will invariably be shouldered by those with the most muted voices in the decision-making process.
In addition, notwithstanding its status as a world leader in developing the latest health care advances as well as for spending on health care, the United States has continued to fall behind other developed countries in health rankings. Even though it spends more on health care than any other country and consumes more than half of the world’s health care resources, the United States has seen increasing mortality and falling life expectancy for people ages 25 to 64, who should be in the prime of their lives (Achenbach, 2019; Zalla et al., 2022). Historically, the United States has failed to recognize the importance of supporting universal access to health care along with programs to improve the overall quality of life for every individual. Data on health care and living conditions are important in helping to identify the gaps in care and services and improve the way resources are used to improve health and well-being.
While the positive contributions of big data and data science to society do not go unrecognized, they are also marred by political determinants, as blatantly observed during times of disaster and emergency, such as a pandemic. This is especially true of health data where responsibility of its governance, as The Lancet Digital Health (2021, p. E684) mentions, “must be driven by public purpose, not private profit.” Efforts to inform the public at large and formulate an appropriate response to an emergency or disaster with proper planning and allocation of resources is highly dependent on not data alone, but accurate and comprehensive data.
However, even highly regarded public health entities struggled to produce data that was not only uniform but comprehensive during the COVID-19 pandemic at a national level, much less at a global level. While seemingly simple, this complex task requires a consensus from respective leaders in public health and government, which may be arduous in part due to party politics; it also requires that efforts be coordinated, uniform, and most of all, inclusive.
In the United States, data collection during the COVID-19 pandemic was not standardized and varied at all levels of government, and even across all states. Sociodemographic information such as race and ethnicity, age, and gender, which is crucial not only for leading quality initiatives related to population health but also for identifying under-resourced communities and knowing who requires immediate attention, was missing in many of the reported cases to the CDC Case Surveillance Restricted Access Detailed Data set (Health Equity Tracker, 2021). At the time of writing this article, standardization of race and ethnicity categories for data collection across state and local jurisdictions did not exist, with some states not recording data for American Indian, Alaska Native, Native Hawaiian, and Pacific Islander racial categories, lumping these populations into other groups, causing notable gaps in the data collected. In addition, sex is recorded only as male, female, or other; mental health and physical health such as disabilities is not recorded, leaving noticeable deficiencies in the ability to identify subpopulations.
The lack of disaggregation of big data is just as hurtful as not collecting data all together, as many groups remain misidentified, unidentified, and unaccounted for. Adding to the complexity is that data sets such as the one described are restricted and require the user to undergo a bureaucratic process to obtain access. If and once achieved, the end user must then determine how to unscramble the packaging of the complex data, often requiring subject matter experts in the field of data science and software programming. Each of these hurdles stems from the lack of uniform policies, which have now resulted in the creation of digital determinants of health data.
Through research in the fields of public health, medical sociology, and social epidemiology, it is now well understood and widely accepted that the social determinants of health affect all aspects of the daily lives of humans. In fact, it is known that the social determinants of health directly affect and often even determine individuals’ and communities’ choices about and access to adequate, affordable, and nutritious food options, safe housing, blue and green spaces, reliable and safe transportation, education and literacy, opportunities for economic stability, and sanitation, among other important factors. In addition to genetics and behavior, the direct significance of all the social determinants of health variables and their contribution to health, wellness, and life opportunities have also come to light. The link between the wide range of health risks and outcomes is now clearly demarcated by conditions in the places where people live, learn, work, and play (Health Equity Tracker, 2021). In simpler terms, because of the social determinants of health, one’s zip code is often a stronger determinant of health than one’s genetic code (Health Equity Tracker, 2021).
Health systems are increasingly investing in programs and influencing policies to address upstream drivers of health, which include the macro-level forces that comprise social-structural influences on health and health systems, and the social, physical, economic, and environmental factors that affect health. In the United States, health systems, for example, have mostly invested in addressing the social determinants of health of their patient populations. From 2017 to 2019, health systems in that country collectively spent $2.5 billion on programs targeting social determinants of health (Horwitz et al., 2020).
What gives rise to the social determinants of health and—more important—why have they disproportionately and detrimentally affected communities for so long? A growing number of health equity scholars, researchers, advocates, and champions support the notion that the social determinants of health are not the fundamental causes of health inequities. Deeply entrenched and pervasive throughout society exist the fundamental instigators or drivers of these unjust and inequitable outcomes called the political determinants of health, which often go undetected, unnoticed, and worse, ignored—despite the incredible driving force they have on all inequities in countries across the world.
Political Determinants of Health Explained
With a baseline understanding of the social determinants of health, the focus then shifts to understanding what the political determinants of health truly are and, more important, how to leverage them to enact sustainable change. Political determinants of health create the structural conditions and the social drivers—including poor environmental conditions, inadequate transportation, unsafe neighborhoods, poor and unstable housing, and lack of healthy food options—that affect all dynamics involved in health (Dawes, 2020). Political determinants of health are more than merely separate and distinct from social determinants of health: they serve as the instigators of the social determinants of health with which many people are already well acquainted. While the social determinants are quintessential for understanding why so many disparate groups have historically faced, and continue to grapple with, health inequities, they do not paint the full picture of how these disparities may be addressed. Looking at health through the lens of political determinants means analyzing how different power constellations, institutions, processes, interests, and ideological positions affect health within different political systems and cultures and at different levels of governance (Dawes et al., 2021).
Dawes (2020, p. 44) defined the political determinants of health as “involving the systematic process of structuring relationships, distributing resources, and administering power, operating simultaneously in ways that mutually reinforce or influence one another to shape opportunities that either advance health equity or exacerbate health inequities.” Dawes (2020) also provided a roadmap for advancing health equity for current and future lawmakers, researchers, scholars, and leaders, focusing on three major aspects of the political determinants of health: voting, government, and policy. To move from simply naming inequities to addressing inequities, work must be performed upstream to address the root causes or origination of these inequities. As such, it is important to understand how political determinants of health leave all people on the social and economic downside of opportunity, access, and advantage—regardless of their political ideologies or how they vote—living and struggling with, and suffering from, less access to affordable, reliable health care, worse health outcomes, and greater risk for early and often-preventable mortality. Simply put, this can be viewed as presented in Figures 1 and 2.
The political determinants of health are, unfortunately, influential in creating relationships between government and policy that result in inequitable outcomes (laws, rules, or regulations that oppress one or more populations), allowing for a few to remain in power and to determine which communities receive vital resources necessary for their well-being and optimal living.
The political determinants of health framework depicts interconnecting or circular arrows demonstrating that political determinants of health operate simultaneously in ways that mutually reinforce one another and concurrently impact or are impacted by a continuum of interacting barriers and interventions. Health equity champions must overcome those barriers and leverage interventions to advance health equity–focused policies and address other competing and equally complex determinants of health. This is a continual strategic process that does not end once a policy is realized but requires constant monitoring and engagement by advocates to determine whether a policy or governmental action is positively or negatively affecting the determinants of health and advancement of health equity (Dawes, 2020).
To explain how these determinants have operated, consider all of the components in a theatrical production that are needed to deliver a performance. The props you see on stage are crucial in the storytelling; they complement the actors’ performances, help set the scene and bring the characters to life, and help draw in the audience for a full immersive experience. Translated to real life, the actors represent each living person, the theatrical performance represents each person’s life, while the props are the social determinants of health impacting every person. Yet, all the while, behind the scenes lies a more crucial and complex operation: the coordination of the props. It is the stage master or coordinator who is responsible for not only securing all the necessary props, but also ensuring that all props are properly queued up at the right point in time of a performance. Imagine if the stage master or coordinator incorrectly queued up a prop, never queued up the prop or, worst of all, forgot a prop altogether. Imagine the impact this would have on the actor, the storytelling, and the overall theatrical performance. Although the stage master or coordinator is never seen or acknowledged, their presence or lack thereof is widely seen and felt and provides a lens and foundation through and upon which the audiences interpret and experience the performances. Their role can contribute to the overall success or detriment of a theatrical performance.
The stage master or coordinator represents the political determinants of health, which—in real life—translates to three major drivers: voting, government, and policy. Together, these three determinants are the most upstream factors of all, which are in concert “behind the scenes,” orchestrating a major production of interrelated downstream factors (the social determinants of health) affecting the populace and governmental and commercial interests, and historically driven by policies based on moral, performance, economic, and national security interests and arguments. The political determinants of health push and pull at the ropes that hoist the props (or, in this example, the social determinants of health) in our lives and help to concretize structural, institutional, interpersonal, and intrapersonal barriers at their intersections.
Collectively, political determinants of health contribute to the imbalance found in each country’s scale of equity, affecting the ability of each human being to live most optimally in a society that champions and upholds equality, equity, and justice over disparity, discrimination, and inequity. As public health leaders, scholars, and others continue to grapple with the lasting effect of the pandemic on health, it is of vital importance that the health inequities that have historically plagued the country and continue to manifest among the population today are acknowledged, understood, and addressed.
Historical Context: The United States as a Case Study
To understand the complexities of the political determinants of health and the vast and systemic nature of intractable health inequities that have plagued our society, it is important to understand the historical context in which these inequities were concretized in our structures, systems, and communities over time. Anecdotal evidence strongly suggests that they are the key drivers that were germinated hundreds of years ago, nourished in the soils of explicit and implicit racism and discrimination, and have been allowed to not only create and sustain, but to grow and exacerbate the very social drivers that health equity and justice champions seek to investigate and eliminate, to close the most pressing health and health care gaps in developed and developing countries.
In the United States, the political determinants of health inequities first reared their head in 1641 when the first legal code to legalize slavery was established by lawmakers in New England. It started with the development, introduction, passage, implementation, amendment, and enforcement of the Body of Liberties law, written and supported by policymakers in each of the colonies who worked with commercial interests that were intent on maintaining their business model, which relied on slavery. It continued with the creation and advancement of additional “facially discriminatory” policies throughout the next 300 years that explicitly prohibited Black and Indigenous populations from addressing their “social determinants of health” needs, including prohibiting these groups from raising their own food, earning their own money, or learning to read and write; limiting their ability to move; and denying them the right to vote and engage in civic discourse on matters that directly impact their health and lives. The result was that it segregated them into communities or reservations unfit for healthy outcomes, among other extremely restrictive policy measures. The negative pervasive consequences of the political determinants of health on minoritized and marginalized groups in America as well as in other countries have been profound.
Today, the impact of “facially neutral” policies on these groups at local, state, federal, and international levels can be observed quite glaringly. In fact, examples of this type of unjustness can be observed in runs throughout so many laws that often exist and are enforced below the radar of equity and justice. Examples include “facially neutral” policies that—once enacted—resulted in diminishing access to safe, affordable housing and displacing hundreds of thousands of racial and ethnic minorities; infrastructure policies that disproportionately burden communities of color; transportation policies that created new and exacerbated existing disparities in racial and ethnic health outcomes; and policies limiting access to health care services, which have collectively resulted in “deserts” and “poverty taxes” in these communities.
Contemporary Impact: Dissecting the Political Determinants of Health
The compounding effects of other factors leading and driving health inequities can now be observed, along with the interrelationships among them; most notably, the COVID-19 pandemic has revealed a long-standing history of social injustices and inequities entrenched in all aspects of society, including its systems. The impacts of slavery, segregation, apartheid, racism, classism, sexism, ableism, and caste have been associated with long-term effects on nearly all health disparities seen today, including premature and often preventable mortality across many diseases and injuries. It is not by chance that certain populations experience higher premature death rates than others, or that women of certain populations experience higher pregnancy-related deaths, or that factors such as poverty, crowded housing, inadequate transportation, food insecurity, medical deserts, and other community attributes associated with social vulnerabilities put a community at higher risk for increased adverse outcomes.
Systemic discrimination still exists, both in plain sight and in more subtle ways. It festers in institutions and systems that have been slow to change. It manifests quietly in unconscious biases and entrenched perceptions. The hurt it causes to communities of color, other vulnerable populations, as well as to society, persists. The negative and deleterious health consequences of political determinants of health are, arguably, equal opportunity offenders because, as Dr. Sandro Galea has stated, “politics shapes and is shaped by underlying social, economic, cultural, and geographic forces” (Galea, 2022, pp 101). As such, political determinants of health leave all people on the social and economic downside of opportunity, access, and advantage—regardless of their political ideologies or how they vote—living and struggling with, and suffering from, less access to affordable, reliable health care, worse health outcomes, and living at greater risk for early and often-preventable mortality.
This begs the question: How have political determinants of health instigated, perpetuated, or exacerbated the poorer health outcomes and lower life expectancies among vulnerable, under-resourced, and marginalized populations in the United States, the United Kingdom, Canada, Australia, Brazil, France, Mexico, Venezuela, and Colombia among many other nations? How did the unequal structural conditions that people are born into, live in, and die in, originate and how have they been sustained?
Understanding this requires individuals to grapple with how the political determinants of health inequitably distribute social, medical, and other determinants and create structural barriers to equity for population groups that lack power and privilege. For virtually any social determinant of health to which one can point, there was some preceding legal, legislative, policy, or regulatory decision that was first made, resulting in the subsequent social determinant. These decisions are the political determinants of health, which have significant influence on health factors. Collectively, these determinants and drivers, experienced across the life course, are what have given way to racism and health inequities in countries around the world.
Voting as a Political Determinant of Health
In many countries, voting is deemed a fundamental civic duty, and yet many individuals fail to recognize or take for granted voting’s impact on their health, well-being, and life expectancy. It is impossible to disentangle the relationship between many of the political processes, strategies, tactics, and rules and the impact they have had and continue to have on health inequities and outcomes. Voting empowers individuals of a society to put in place and/or bypass decision makers (Dawes, 2020). Better explained, voting affords all, at an individual level, a voice to engage in policy solutions for issues directly impacting not only themselves but their respective communities. It extends a representation of themselves and their interests into government by placing like-minded individuals aligned with their views, whether religious, economic, political, or cultural in nature, in seats of government charged to act in their best interest. Yet despite voting being a significant aspect of the political determinants of health, many fail to make the connection between voting and their own health outcomes and premature deaths, which are disguised behind decisions embedded within social determinants directly impacting their daily living and their surrounding communities. Several factors exist that act as individual scenarios but also add to the interplay of the political determinants, that when considered together, explain the governing dysfunction and mistrust by the public.
While some voluntarily choose to exclude themselves from this process (voter apathy), other population groups have been intentionally excluded from this process. Over the years, opportunities for civic engagement have been stymied by continual efforts to restrict, suppress, subvert, or obstruct voting by groups who have limited power and privilege. The overt exclusion from civic engagement through historical and contemporary methods of gerrymandering, which include coercive attempts to restrict ballot access to citizens on the downside of elite American privileges, continues to perpetuate inequities. Poll taxes, voting restrictions, such as voter identification laws, purging voter rolls of irregular voters, minimizing the opportunities for early voting, requiring voter identification, and closing or moving polling places farther away from voters, have disproportionately affected racial and ethnic minority communities and lower-socioeconomic status individuals (Dawes, 2020). Yet, it is known that voting rights are essential for creating and advancing health equity. As voter suppression occurs, the individuals most impacted by inequities, who need a fair adjudication of their issues, are the same individuals who find themselves locked out of the political system (Dawes, 2020).
Money is another factor that impacts the political determinants of health in countries. For any candidate to participate in the political process, especially elections, an extensive amount of money goes toward campaigning alone. In the United States, both congressional and presidential spending for the 2020 election surpassed, and nearly doubled, the previous election, making it as the most expensive in the nation’s history at $14 billion (OpenSecrets.org, 2020). This scaling up of campaigning is another barrier for an ordinary citizen to hold a seat in government. Lobbying expenditures in America also act as a significant financial barrier to campaigning, having reached a total of $3.49 billion in 2020 (Duffin, 2021). Depending on the policy issue and its implications, large amounts of effort and money can be spent to assure a political win, backed by large corporations, agencies, and special interest groups. Indisputably, lobbying can help sway the health equity needle from pointing to a true north if advocates’ health equity agendas are out of alignment with commercial interests and government investment values.
This discussion on political determinants of health would not be complete without considering the increasing and shifting demographics toward a rise in racial and ethnic diversity within developed countries owing to globalization (Jensen et al., 2021). In the United States, for example, although progress has been made relative to diversifying the federal government, there has been a growing physical disconnect between those represented and those who represent them, leading to an ever-widening gap in health inequities and a dearth of policies and programs addressing them (Schaeffer, 2021). This does not even account for the potential growth that is projected to occur due to global migration propagated by protracted conflicts, climate change, and environmental degradation, which will intensify the need for equity-focused and inclusive public policies (United Nations, n.d.). Of equal concern is the process of congressional apportionment, or representation based on population size. With the dramatic increase in the U.S. population and no more addition of seats to the House of Representatives, one individual is said to be representative of an even larger population than before (Desilver, 2018). In view of both facts, the question arises: To what extent can one representative truly be representative of so many?
The fourth major factor affecting the political determinants of health is a powerful tool that, while acknowledged as a symbol of progress and advancement globally, has also been weaponized in many instances into a destructive force: technology. Collectively, technology is recognized by its many faces, such as big data, television, the Internet, and, arguably the most popular during the past year, the multitude of social media platforms such as LinkedIn, Twitter, Facebook, Instagram, and TikTok. Though it has many great uses, it has also aided in counterproductive efforts such as abetting the rapid spread of misinformation as well as allowing for the disruption and interference of crucial processes, such as in the electoral process (Dawes, 2020). In this light, technology can either aid or hinder civic education and advancement. As a nation working to remedy and improve upon its current state of affairs, this is one aspect that the United States, or any country for that matter, cannot afford to undermine, much less ignore.
Government as a Political Determinant of Health
Another political determinant of health is government. Although key, voting alone is not sufficient to meaningfully address inequities (Dawes, 2020). While the populace of a country may understand the process associated with voting and its impact, government and its complex inner workings seem to be far less understood—understandably so, whether in America or in other societies across the globe. Government, like the rest of society, is not exempt from partaking and contributing to the socio-ecological model that exists in society; while simultaneously dealing with structural barriers, government must also finesse the interplay between intrapersonal, interpersonal, and institutional relationships brought about by policy.
Individually considered, each is a contributing factor or can act as a barrier to health equity and is the source of the scarcity of inclusive and equitable policies. Collectively, this interplay adds another layer of difficulty to expand the inclusivity in policies when considering the interplay between structural and other forms of barriers sanctioned by the government through the introduction or non-introduction, the enactment or non-enactment, the enforcement or non-enforcement, or the clawback or repeal of policy.
Unfortunately, the list of challenges within government alone is extensive. Consider again other socioeconomic factors of the demographics of those seated in the United States’ federal government positions; most are far-removed from the people they are thought to represent. Most policymakers are more educated and affluent than the population they represent, making the opportunity for most Americans to sit at this level of government very distant (Chinoy & Ma, 2019). The lack of representation from all walks of life—especially those who experience inequities, contributes to the dearth of inclusivity and equitable policies generated by policymakers. The result, instead, is a government that mirrors and operates with the social biases and social maladies found in society at large: racism, discrimination, misogyny, ableism, and homophobia, to name a few.
Policy as a Political Determinant of Health
Policy as a political determinant of health serves to concretize government decisions. However, it is important to note that this determinant alone should not be revered as the ultimate, but as part of the panoply of all political determinants acting in tandem (Dawes, 2020). An initial success on this front does not necessarily equate to a final victory, as efforts geared toward the first two political determinants may be underway to quash policy. Thus, it is important to note that a strategic approach as well as advocacy efforts also play substantial roles in successfully aiding the passage of a policy and, ultimately, a political interest.
This system has rarely valued each group equally or realized the long-term implications of policies on the health of its citizenry. A slew of health problems (high obesity rates, maternal mortality, infant mortality, gun violence, depression, opioid addiction, substance use disorders, diabetes, heart disease, cancer, HIV/AIDS, and many more)—including COVID-19—can be firmly linked to political action or inaction (Dawes, 2020). In American history, the combination of having proponents or advocates of a policy and well devised arguments has proved to successfully support the passage of policy; four arguments in particular, morality, performance, economic security, and national security, have been instrumental to its passing. Undoubtedly, advocacy is a vital role in the continual strategic process serving as a litmus test for policy and governmental action, and their combined effects on advancing health equity (Dawes, 2020).
Jessica’s Story: A Case Study
A pregnant 19-year-old woman, Jessica is simply trying to survive and work toward a better future for herself and her growing child in a less than desirable environment. She lives in an apartment in a low-income neighborhood. Convenience stores and fast-food restaurants dot every intersection, sidewalks are scarce, city buses do not run through her community, health care providers refuse to operate in the community owing to poor reimbursement rates from Medicaid, and the local schools are failing.
Each of these neighborhood conditions was politically determined. Politicians determined whether to create and keep housing segregation in place and whether to expend resources to build sidewalks, parks, or recreational facilities in the community so individuals can walk, play, and exercise. Politicians decided whether to create a bus route through the community to connect it with other more resourced communities or whether to incentivize grocery stores to operate in the community and provide access to fresh fruits, vegetables, and meat.
When community members decided to take matters into their own hands by trying to establish a community garden and operate a farmers’ market, politicians failed to issue a permit allowing them to proceed with the project. Politicians also influenced decisions to cover obstetric, gynecologic, and other health services under government health insurance programs or to increase reimbursement rates to incentivize providers to serve poorer populations. Historical redlining has created many of these microcosms of vulnerable communities within even flourishing cities and neighborhoods (Rothstein, 2017).
Jessica’s dilemma highlights the trickle-down effect of policies put into place by elected officials that do not consider the humans who are bound to the regulations they create. These decisions made by policymakers impact Jessica’s birth experience: Due to a lack of insurance, she gives birth to a child 9 weeks prematurely, owing to undiagnosed preeclampsia, and is not given the tools to help her or her child to thrive and grow as a healthy family. Far too often, Jessica’s story is a reality for Black, Hispanic/Latin(o/a/x), and Indigenous populations. The systemic neglect experienced by disadvantaged communities restricts and limits their ability to control the air they breathe, the food they eat, access to transportation, and the quality of their health care. It is up to those in power to make more ethical choices and decisions, and to remain cognizant of the fact that these are living, breathing, human beings who are being disregarded and neglected by the very political structures established to protect minoritized and marginalized population groups.
No two political systems are ever exactly alike, regardless of their definitional classification. This becomes irrefutably true when you drill down further and begin to consider the differing machinations of more local governance. Even the United States of America is composed of fifty distinct states, each with slightly different political systems owing to differing interests and stimuli. And yet, even though no two systems are ever exactly alike, every political system has the shared propensity and capability of impacting the health outcomes of its citizenry due to the political determinants of health. By first understanding that each and every governmental institution has the potential to leverage the political determinants of health, either for the benefit or to the detriment of the people it exists to serve, only then can one begin the arduous process of ensuring that these determinants are in fact prioritized for the greater good.
If, as the World Health Organization describes it, health equity is the absence of avoidable or remediable differences in health among groups of people, then it can logically be concluded that the presence of health inequities is indeed an avoidable outcome (WHO, 2018). Put more succinctly, actionable steps can and should be taken to remedy health inequities. Specifically, those steps begin with the act of leveraging the political determinants of health. While the political determinants of health may be unfamiliar territory for some, the United States has a long history of leveraging them to exacerbate disparities, which means a playbook already exists for leveraging them to ameliorate disparities.
The social, environmental, and other determinants of health were designed, implemented, and perpetuated by political, legislative, regulatory, or legal decisions. The social determinants, environmental determinants, health care determinants, even behavioral determinants of health all owe their existence and pervasiveness to the political determinants of health. As such, it is incumbent upon researchers, leaders, and community advocates to more effectively highlight the nexus between the political determinants of health and their downstream impacts, in order to make the compelling case for prioritization of health equity. Health equity leaders must be as well-versed in the political determinants of health as they are in every other determinant if they are to ever truly achieve a more equitable tomorrow for all population groups around the globe.
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