In the September 2023 Issue of the Quarterly

From the Editor
Population Health

In this issue of the Milbank Quarterly, readers will find Perspectives and original scholarship articles on such diverse topics as complexity in health care, the relationship between electoral democracy and working-age mortality, the role of primary care in advancing health equity, measures of patient trust in primary care, and lessons from a five-state study of the public health workforce.

 In “Toward a Values-Informed Approach to Complexity in Health Care: Hermeneutic Review,” Trisha Greenhalgh and colleagues examine the concept of value complexity, i.e., complexity arising from differences in people’s worldviews, interests, and values, which can lead to mistrust, misunderstanding, and conflict among stakeholders.  Reviewing the relevant literature from multiple disciplines, the authors extract key theoretical themes, including power, conflict, language and framing, meaning-making, and collective deliberation.  From this synthesis, they derive “simple rules” that offer recommendations for a more values-informed approach to understanding complexity in health care.

The meaning of health in health care generally has been poorly defined and relies primarily on a narrow, biomedical disease model.  In “The Profound Implications of the Meaning of Health for Health Care and Health Equity,” Kevin Fiscella and Ronald M. Epstein argue that a national dialogue is needed to achieve consensus regarding a holistic definition of health that promotes health care transformation and health equity.  Building upon the 2023 report by the National Academies of Sciences, Engineering, and Medicine on achieving whole health, the authors outline several key steps for operationalizing a holistic meaning of health in health care.  Among the steps are national leadership by federal agencies, intersectoral collaborations among diverse communities, organizational and cultural change in medical education, and implementation of high-quality primary care.

Working-age mortality rates are high and rising in the United States.  Although several reasons for this trend have been hypothesized, the potential role of democratic erosion has been overlooked.  In “Electoral Democracy and Working-Age Mortality,” Jennifer Karas Montez and colleagues examine the association between electoral democracy and working-age mortality and assess how economic, behavioral, and social factors may have contributed to it.  Using the State Democracy Index (SDI), an annual summary of each state’s electoral democracy from 2000 to 2018, merged with annual age-adjusted mortality rates for adults 25–64 years in each state, the authors estimate the association between the SDI and working-age mortality from all causes and six specific causes within states, adjusting for political party control, safety net generosity, union coverage, immigrant population, and stable characteristics of states.  They find that increasing electoral democracy in a state from a moderate level (defined as the third quintile of the SDI distribution) to a high level (defined as the fifth quintile) was associated with an estimated 3.2% and 2.7% lower mortality rate among working-age men and women, respectively, over the next year.  Increasing electoral democracy in all states from the third to the fifth quintile of the SDI distribution may have resulted in 20,408 fewer working-age deaths in 2019.  The democracy–mortality association mainly reflected social factors and, to a lesser extent, health behaviors, and they caution that erosion of electoral democracy is a threat to population health.

While it has been noted that civically active people may experience better health and that societies with more equitable health and health care may experience healthier civic life, the role of primary care in advancing civic engagement has received little study.  In “The Role of Primary Care in Advancing Civic Engagement and Health Equity: A Conceptual Framework,” Daniel R. S. Habib and colleagues review current literature on the links among health, civic engagement, and primary care, and propose an integrative  conceptual framework that highlights the interconnectedness of primary care structures, health equity, and civic engagement.  The authors contend that health and civic engagement are mutually reinforcing, and that responsibility for promoting both health and civic engagement is shared by providers, community organizations, educators, and policymakers, as well as democratic and health systems, yet these entities rarely work together.  Future work is needed to inform policy and practice to bolster primary care as a means for promoting health and civic engagement.

Cultural racism is a major contributor to all other dimensions of racism that produce and maintain racial health inequities.  Yet, it has received relatively little attention in the public health literature.  In “The Water Surrounding the Iceberg: Cultural Racism and Health Inequities,” Eli Michaels and colleagues elucidate our understanding of cultural racism and how it operates in conjunction with the other dimensions of racism to produce health inequities.  The authors conducted a multidisciplinary review of theory and empirical evidence on the consequences of cultural racism for social and health inequities, finding that it surrounds and bolsters structural, institutional, personally mediated, and internalized racism, and undermines health through various material, cognitive/affective, biologic, and behavioral mechanisms across the life course.  They offer directions for future research and interventions on cultural racism.

The COVID-19 pandemic exposed many shortcomings of the United States public health system, including an understaffed, underpaid, and undervalued public health workforce.  To rebuild that workforce, the American Rescue Plan (ARP) Act appropriated funds to create 100,000 new public health jobs.  As part of this initiative, the Centers for Disease Control and Prevention (CDC) distributed roughly $2 billion to state, local, tribal, and territorial health agencies for use between July 1, 2021, and June 30, 2023.  In “Politics and the Public Health Workforce: Lessons Suggested from a Five-State Study,” Michael Sparer and Lawrence Brown interviewed leaders at the CDC and other experts on the nation’s public health workforce, and visited the states of Kentucky, Indiana, Mississippi, New York, and Washington to examine the implementation and impact of the ARP workforce funds as well as several state-based initiatives.  They found that states are not spending the CDC workforce funding in a timely fashion, and that the state-based initiatives rely on the same overarching strategy to gain the support of local elected officials by providing funds directly to local health departments.  Even with increased funding, the nation’s public health workforce challenges will not be met until public health is made a more attractive career path with higher pay, improved working conditions, and greater training and promotion opportunities.  The authors recommend a closer look at the politics of public health, including the role played by county commissioners, mayors, and other local elected officials, in order to formulate a political strategy to persuade these officials that their constituents will benefit from a better public health system.

It is well recognized that an ongoing, trusting relationship between clinicians and patients has shown demonstrable value to primary care.  However, there is currently no measure of trust in general use, and none endorsed for use by most value-based payment programs.  In “Measuring Trust in Primary Care,” Zachary Merenstein, Jill Shuemaker, and Robert Phillips report on their search for existing measures of patient trust in primary care clinicians.  Their scoping review found four tested measures for assessing patients’ trust in primary care clinicians.  Of these four, the revised Trust in Physicians Scale and the Wake Forest Physician Trust Scale were deemed the most tested and viable options for general use as patient-reported outcome measures in primary care.  They argue that renewed national interest in trust in health care should focus on the capacity to measure trust in relation to outcomes, and on how it is produced or lost in order to assist physician practices and health systems in earning it.

The scaling of effective innovations in health and social care is vital to increasing their impact.  In “Evidence on Scaling in Health and Social Care: An Umbrella Review,” Roberta de Carvalho Corôa and colleagues conducted an umbrella review to synthesize the evidence base on scaling and to identify current knowledge gaps.  The authors assessed 58 systematic reviews, most of which reported on scaling in low- and middle-income countries, with many aimed at infectious diseases or maternal and child health and mainly focused on interventions, barriers and facilitators, frameworks, scalability, and costs.  The WHO/ExpandNet scaling definition was most frequently used.  Domains most reported as influencing scaling success were building scaling infrastructure (e.g., creating new service sites) and human resources (e.g., training community health care providers).  The authors conclude that the evidence base on scaling is evolving rapidly as reflected by publication trends, the range of focus areas, and diversity of scaling definitions.  However, common efforts are needed to ensure that scaling expands the impacts of health and social innovations to broader populations.

The growth in rural hospital closures has raised concerns about diminished access to hospital-based care for rural populations.  In “Structural Factors and Racial/Ethnic Inequities in Travel Times to Acute Care Hospitals in the Rural US South, 2007–2018,” Arianna Marie Planey and colleagues sought to (1) characterize the change in rural hospital supply in the US South between 2007 and 2018, accounting for health system closures, mergers, and conversions, and (2) quantify spatial accessibility in 2018 for populations most at risk for adverse outcomes following hospital closure (i.e., Black and Latinx rural communities).  The authors also used multilevel modeling to examine relationships between structural factors and disparities in spatial access to care, using estimates of network travel distance and time to the nearest and second nearest operating hospital in the years 2007 and 2018.  Their analysis revealed that 72 (10%) rural counties in the South had ≥1 hospital closures between 2007 and 2018, with nearly half of closure counties (33) losing their last remaining hospital.  Overall, 49% of rural tracts experienced worsened spatial access to their nearest hospital, whereas smaller proportions experienced improved (32%) or unchanged (18%) access between 2007 and 2018.  Tracts located within closure counties had longer travel times to the nearest acute care hospital compared with tracts in nonclosure counties.  Places affected by rural hospital closures had greater travel burdens for acute care, and across the rural South, racial/ethnic inequities in spatial access to acute care are most pronounced when travel times to the second nearest open acute care hospital are accounted for.

In the past three years, many medical schools have made public statements committing themselves to become antiracist institutions.  While structural racism no longer seems as controversial in the academic community, challenges remain in how this basic understanding gets translated into medical education practice.  In “Can US Medical Schools Teach About Structural Racism?” Anthony Schlaff and colleagues conducted key informant interviews to learn about the challenges and best practices from schools deemed to be positive deviants in teaching about structural racism.  Their interviews suggested that even those schools deemed positive deviants in the level of teaching about structural racism faced significant barriers in providing a robust education.  They argue that significant structural change, perhaps far beyond what most schools are willing and able to undertake, will be necessary to assure that future US physicians can fully understand and address structural racism as it affects their profession, their practice, and their patients.

In closing, we invite readers to visit the Quarterly’s website for timely opinion pieces on important policy issues (  Recent contributions include:

  • John McDonough on building an anti-monopoly movement in the United States;
  • Sara Rosenbaum and Kay Johnson on modernizing the federal Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) Program;
  • Morgan Shields and Heidi Allen on taking a step forward in measuring and reporting patient experience of inpatient psychiatry; and
  • Sandro Galea on reaffirming the value of diversity in light of the recent Supreme Court decision on college affirmative action.

Cohen AB. In the September 2023 Issue of the Quarterly. Milbank Q. 2023;101(3):0823.

About the Author

Alan B. Cohen became editor of The Milbank Quarterly in August 2018. He currently is a research professor in the Markets, Public Policy, and Law Department at the Boston University Questrom School of Business, and professor of health law, policy and management at the Boston University School of Public Health. He previously directed the Scholars in Health Policy Research Program and the Investigator Awards in Health Policy Research for the Robert Wood Johnson Foundation. Earlier in his career, he held faculty positions at Johns Hopkins University and Brandeis University, and spent 8 years at the Robert Wood Johnson Foundation. He is a member of the National Academy of Social Insurance. He received his BA in psychology from the University of Rochester, and his MS and ScD in health policy and management from the Harvard School of Public Health.

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