The concept that health comes with significant social determinants is everywhere we turn. This idea – that health and health inequities are driven by “the conditions in which people are born, grow, live, work and age [and are] shaped by the distribution of money, power and resources” – is increasingly the focus of articles, research projects, toolkits, new courses and new conferences. And that is great!
The medical and public health communities widely recognize that the social determinants of health (SDoH) deserve the attention of policymakers, public health professionals, medical schools and researchers. There are calls for increased training in SDoH and health care providers now have an array of tools to screen for such variables as socioeconomic status, hunger, education, employment, physical environment, and social support. Scholarship surrounding these factors is also on the rise. My own search of the academic literature, for example, shows that articles with “social determinants of health” in the title jumped from 45 in 2007 to 1092 in 2017.
This improved academic insight into the role of SDoH leads to a natural question about root causes. Specifically, if these social determinants shape health, then what shapes these social determinants?
As important as that question is, it is one the medical profession tends to duck. Perhaps it is because of a sense of helplessness when asked to address factors outside the four walls of the medical clinic, or fears of medicalizing issues like economic insecurity. Or perhaps it is because the answer serves up a more uncomfortable truth: the root causes of health and, thus, health disparities are driven as much by policy (and politics) as by any other cause.
Let’s be honest, these political determinants of health – the PDoH if you will – don’t get nearly the attention they deserve from the medical profession. Yet, there is nothing radical in acknowledging the part played by political choices in affecting the nation’s health. Think of areas as disparate as vaccines, air quality, seat belt safety and smoking cessation; all cases where the public’s health was better off for the choices made.
There are many other areas that perhaps less obviously (but no less importantly) impact health, where politics and health outcomes mix, including the oversight and regulation of corporations, immigration and refugee politics, responses to natural disasters, etc. These political decisions upstream have large health effects downstream. This is firmly captured in the movement known as Health in All Policies.
Right now, however, politics is likely having an outsized influence on health. To be clear, I am not referring to the many reports of higher levels of stress, anxiety and depression the current political climate is afflicting on many Americans. Rather, I am talking about the current ascendency and empowerment of political views that subordinate good health outcomes to other cultural, philosophical and societal objectives, such as profit-making, prioritizing religious beliefs, and satisfying populist impulses, among others.
Here are some other examples:
- Access to care: political efforts are still ongoing to dismantle the Affordable Care Act, which would strip many of their ability to have affordable insurance, and would impact millions who have pre-existing conditions.
- Drug prices: high prices have hurt people with conditions like diabetes and cancer. Many patients cannot afford life-saving medications, or have to skip doses. Even the ability of the nation’s largest payer for prescription drugs–Medicare–is prevented by law from negotiating down such prices .
- Reproductive and women’s health: access to birth control and abortion are affected by political decisions and funding (such as through Title X) at the federal and state level.
- Gun violence: from government funding of research activities to prevention efforts, decisions are frequently linked to political processes and donations.
- The health of immigrants, especially those seeking asylum: from the Muslim ban to refugee quotas to the situation on the US-Mexico borders, those are all tightly linked to political decisions and affect vulnerable populations, children, and even the U.S. workforce.
The political dimension of these issues is manifest, and yet, there is nearly a taboo about acknowledging this in classroom discussions and on the wards. This needs to change: we should be engaging in open and robust discussions of how politics affects and shapes our patients’ lives, our communities, and the SDoH themselves.
“Health is a political choice”, writes Ilona Kickbusch in a 2015 editorial in the journal BMJ, “and politics is a continuous struggle for power among competing interests. Looking at health through the lens of political determinants means analyzing how different power constellations, institutions, processes, interests, and ideological positions affect health…”.
We must help our future health professionals understand these forces, and engage in discourse by creating educational content that includes governance, lobbying and policymaking. We should teach students advocacy skills, institutionally support student groups who engage in political discourse and activism, and promote safe space for debate by emphasizing tolerance and respectful dialogue.
We must also support research on ‘political epidemiology’ to explore and document the causal effects of political decisions on the health of populations. For example, one study found that people living in democracies enjoy better health than those in repressive regimes. While this seems intuitive, there are variations in health correlated with more subtle political commitments to universal health care that countries have embraced at varying levels.
I expect pushback and expect to hear excuses like “medical school is about health and disease” or “we cannot be partisan” or “there is no room in the curriculum.” I get it. Many healthcare providers may feel it would not be pragmatic to mix medicine and politics. This may stem from an effort to ensure objectivity and protect the patient-provider relationship. There may also be concerns that their institutions will look askance at political activism and perhaps even retaliate.
But there is pragmatism in the counter-argument as well. Once we acknowledge the role of politics in shaping health, ignoring that becomes a cop-out and shortchanges our students and patients. It is time we acknowledge politics head-on in our medical education system and open the door for an exploration that goes beyond the social determinants of health.
The coming midterm elections provide a wonderful opportunity to bring up these issues with our students. Healthcare is already one of the top-priority issues for the upcoming midterms and we must make sure students are not only aware of it, but have opportunities to partake in the process as important stakeholders in the field.
One of Rudolph Virchow’s frequently used quotations goes like this: “Politics is nothing but medicine at a larger scale.” I’d argue for a more direct rewording and acknowledge just how much health itself depends on politics. It is time to bring the Political Determinants of Health to the forefront.
Ranit Mishori