A Vote for Health

Public Health
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It is well established that politics, and the mechanisms of political action, have an important impact on the health of populations. The very ubiquity of political forces—that in many ways shape all aspects of the world around us—makes it easy to forget that political action should be central to our thinking about all determinants of health. Studies that have assessed public perception of the drivers of health repeatedly show that politics ranks low among drivers of health reported by the general public. Some of this dynamic changes when elections are looming, a shift that may be more pronounced during especially contentious elections. In the context of an upcoming US federal election that threatens to be more divisive than many in recent history, the role of politics in shaping health re-emerges as a vivid consideration, appropriately so given the potential consequences of the election to come. How then should we be thinking about the political drivers of health as we head into the fall? How can those whose work is concerned with creating healthy populations think about the challenges the United States faces before and after the upcoming presidential election? I offer three considerations in this regard that might help guide our engagement with politics throughout 2024.

First, in a country that has been for much of the past decade evenly divided along partisan lines, the concerns of public health should not be consigned to similar partisan lines. This therefore calls on us to engage political actions and actors dispassionately, evaluating how they might affect the health of populations, without casting our lot in an explicitly partisan way. That does not mean avoiding the potential harms that can be brought about by particular political actors whose actions can harm health. I have previously written about the dangers to health posed by the first Trump presidency, largely around the challenges presented by divisiveness and disinvestment in health. Both of those concerns were realized, in particular with the onset of the COVID-19 pandemic during the last year of the Trump presidency. Disinvesting from both public health and the social factors—stable housing, equitable employment, safe neighborhoods—that generate health is harmful to health, and it is not partisan to encourage voting for political leaders who will promote the conditions that create health. It also seems reasonable to take seriously threats to representative democracy that could destabilize the country by bringing about the kind of large-scale unrest that we know harms both physical and mental health.

Second, even as we think about the influence of political action on health, it is worth keeping in mind that health itself influences political and electoral action. This was well demonstrated in studies conducted after the 2016 US election that showed how areas of the country where health had receded were much more likely to have voted for President Trump, than were areas where health had improved. There is little that should surprise us about this on careful reflection. If one is living in an area where health is obviously declining, a vote for an insurgent populist who promises a reboot of the national approach to many matters is a rational vote. This phenomenon is not restricted to the United States. Studies in Europe have shown that persons who report poorer health, or who report greater levels of disability, are substantially more likely to vote for populist parties and candidates than are those who report better health. This reinforces the importance of efforts to generate health at all times. If poor health is likely to lead to the election of candidates who, ironically, are less likely to invest in health, it is in our collective best interest to ensure that everyone is as healthy as possible in order to maintain a trajectory of positive health for whole populations.

Third, health can have a particular role to play in catalyzing ideas about candidates and sifting through electoral choices. Health became entangled with partisan considerations during the COVID-19 pandemic. This had the unfortunate consequence of aligning health recommendations with particular political parties and making engagement with health decision-making contingent on party affiliation. This also chips away at the potential unifying role that health can play as one of our few universally held values. It is, therefore, incumbent upon those who engage in the business of health to steer away from approaches that are seen as overly partisan, centering a shared aspiration for a healthier world, and acknowledging that such can come—indeed should come—about as the product of action by either political party. This pushes us to surface shared goals, such as the health of the next generation and the preservation of a planet that can sustain such health, without over-reliance on solutions that are the province of one political party or another. I realize that this is perhaps challenged by the hardening of approaches held by the current dominant political parties in the United States, where, in reaction to one another, they often take positions that seem to defy consensus bridge-building. But it remains the responsibility of those of us who are committed to a long-term vision of a healthier world to point to areas of consensus, motivated by shared concern for our collective well-being.

We are entering a challenging territory in the national conversation that is relevant to the promotion of population health. When we recognize—as we now readily do throughout the field—that health is a product of the world around us, of how we live, work, and play, it is impossible to separate decisions that influence these very conditions from decisions that influence health. That lies at the heart of health in all policies approaches and should unquestionably be a part of our thinking about encouraging the creation of a healthier world. However, in a highly partisan and divided national and cultural landscape, particular policy positions are not infrequently seen as unyieldingly linked to specific party affiliation and distant from their very real consequences for the lives of people. Issues like climate change, structural racism, and equitable wages—all central to the creation of a healthy country—are reliably divisive, and it is difficult to find rhetorical approaches that bridge these divides to the end of forging viable ways forward and generating health. 

At the same time, there are grounds for optimism, even in a fraught political season. There are promising efforts, particularly at the local political level, that have taken creative approaches, forging bipartisan consensus and finding ways to invest in the structures that generate health. And, while divisive politics have characterized the country over the past decade, there are signs of population wariness about this division, characterized by a desire to move beyond an overly partisan world to one where solutions can be found to very real problems. There is a place for health to help bridge some of these divides, to be that bridge, suggesting that our careful engagement—surfacing values that unite, highlighting what may work and may not, and not allowing ourselves to be swept away in the particular partisan fervor of the moment—may be a vote for future health indeed.

Galea S. A Vote for Health. Milbank Quarterly OpinionMay 24, 2024.  

About the Author

Sandro Galea, a physician, epidemiologist, and author, is dean and Robert A. Knox Professor at Boston University School of Public Health. He previously held academic and leadership positions at Columbia University, the University of Michigan, and the New York Academy of Medicine. He has published extensively in the peer-reviewed literature, and is a regular contributor to a range of public media, about the social causes of health, mental health, and the consequences of trauma. He has been listed as one of the most widely cited scholars in the social sciences. He is chair of the board of the Association of Schools and Programs of Public Health and past president of the Society for Epidemiologic Research and of the Interdisciplinary Association for Population Health Science. He is an elected member of the National Academy of Medicine. Galea has received several lifetime achievement awards. Galea holds a medical degree from the University of Toronto, graduate degrees from Harvard University and Columbia University, and an honorary doctorate from the University of Glasgow. His book Within Reason was published by University of Chicago Press on December 1, 2023.

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