Health Policy Journal Club, February 2021
Political Determinants of Health

Readings

The political and moral determinants of health 

1. Dawes DE. Health inequities: a look at the political determinants of health during the COVID-19 pandemic. Americal Journal of Health Studies. 2020;35(2):77-82. 
2. Berwick DM. The moral determinants of health. JAMA. 2020;324(3):225-226. 

Political determinants across the US and globally 

1. Montez JK, Beckfield J, Cooney JK, Grumbach JM, Hayward MD, Koytak HZ, Woolf SH, Zajacova A. US state policies, politics, and life expectancy. Milbank Quarterly. 2020;98(3):668-699. 
2. The Lancet-University of Oslo Commission on Global Governance for Health. The political origins of health inequity: prospects for change. The Lancet. 2014;383.

Health equity in all policies 

1. Pepin D, Winig BD, Carr D, Jacobson PD. Collaborating for health: health in all policies and the law. The Journal of Law, Medicine & Ethics. 2017;45(1). 
2. Health in All Policies. Colorado Association of Local Public Health Officials. Includes case studies in addition to background and recommendations listed on the page. 
3. Armijo G, Kauffman M. Health in all policies in Denver, CO: Moving from plans to equitable development outcomes. Chronicles of Health Impact Assessment. 2019;4(1).

Key takeaways from the readings

The political determinants of health shape the social drivers of health equity.

Dawes DE. Health inequities: a look at the political determinants of health during the COVID-19 pandemic. Americal Journal of Health Studies. 2020;35(2):77-82.

Political determinants of health lie even further upstream than the social determinants of health. This reading presents the example of increased asthma rates in a community of color. Through the lens of social determinants of health, one might conclude the cause was placement of a bus depot and interstate highway near substandard housing. Looking further upstream through the lens of the political determinants of health, one can see how the placement of the bus depot and interstate stemmed from redlining policies, displacement of minorities, and zoning decisions. If the minority community had had political power, those decisions would have been made differently.

There is an urgent need to examine the political determinants of health, given current decreasing life expectancy, worsening health outcomes, and declining health care options. As is seen in other pandemics and natural disasters, COVID has disproportionately impacted racial and ethnic minorities, people with disabilities, and those with lower socioeconomic status.

Comments from discussion participants:

·      Why are we turning the social determinants of health into a medical problem and making health care systems responsible?

·      We talk a lot about the social determinants of health – but take another step back and say, why is that the way it is?

·      Moving policy forward is slow, and not assured.

·      Data is a powerful factor. It needs to be framed in a way that works across the aisle.

·      Good resources on framing include the FrameWorks Institute and the book Don’t Think of an Elephant.

For solutions to address the social or political determinants of health, a new moral compact must be reached.

Berwick DM. The moral determinants of health. JAMA. 2020;324(3):225-226. 

Berwick notes “the power of … societal factors is enormous compared with the power of health care to counteract them.” Despite the evidence on the social determinants of health, most economic investment in health is made much further downstream.

There are two possible solutions: raise taxes to improve the social determinants of health (investing in housing, food, early childhood education, transportation, etc.), or shift some fraction of health expenditures from downstream “repair shops” upstream to address those social determinants. While either could be done logistically, they are both politically infeasible in a country that lacks a strong sense of social solidarity.

A morally guided campaign for better health would include:

·      US ratification of basic human rights treaties and international conventions

·      Realize in statute health care as a human right

·      Restore leadership to reverse climate change

·      Radical reform of the criminal justice system

·      End policies of exclusion and achieve compassionate immigration reform

·      End hunger and homelessness

·      Restore order, dignity and equity to democratic institutions and ensure every person’s right to vote is counted equally

Comments from discussion participants:

·      In the US we are not agreed on whether equity is a good thing or a bad thing.

·      You can make a moral stand, but you need to figure out how to turn it into [political] sausage.

·      We need to take accountability for our past and responsibility for our future.  

More liberal versions of policies in US states are generally associated with a longer life expectancy.

Montez JK, Beckfield J, Cooney JK, Grumbach JM, Hayward MD, Koytak HZ, Woolf SH, Zajacova A. US state policies, politics, and life expectancy. Milbank Quarterly. 2020;98(3):668-699. 

Policies and political choices are “the causes of the causes of the causes of geographic inequalities in health.” Over the last several decades, decentralization of policymaking has led to states playing an increasingly large role in the policy context in which Americans live. In 2017, life expectancy in the US ranged from 74.6 in West Virginia to 81.6 in Hawaii. From 1970-2014, most states moved away from the center towards a more liberal or more conservative orientation.

This study examined the impact of policies on life expectancy from 16 domains: abortion, campaign finance, civil rights and liberties, criminal justice, education, gun control, health and welfare, housing and transportation, immigration, private sector labor, public sector labor, voting, taxes, marijuana, tobacco, and lesbian, gay, bisexual and transgender (LGBT) rights. Ten of these domains had a significant association with life expectancy; of these, 8 had a longer life expectancy associated with a more liberal orientation: tobacco, immigration, gun control, LGBT rights, abortion, private labor, and civil rights. Exceptions were noted for marijuana policies and voting.

If all states had the maximum liberal score on policy measures examined, US life expectancy would be 2.8 years longer for women and 2.1 years longer for men.

The global political determinants of health that unfavorably affect the health of some groups relative to others are unfair and some harms may be avoided by improving global governance.

The Lancet-University of Oslo Commission on Global Governance for Health. The political origins of health inequity: prospects for change. The Lancet. 2014; 383.

The global political determinants of health refer to the transnational norms, policies and practices arising from political interaction across all sectors that affect health. Many instruments that exist at a national level to create, interpret or enforce laws do not exist at the global level. Further, significant power asymmetry marks the global political landscape. Some United Nations bodies (like the World Bank) have governance and voting powers weighted by financial contribution. The influence of private firms is also powerful; the capital of the top five tobacco, beverage, and pharmaceutical firms exceed most national economies.

There are five dysfunctions of the global governance system that adversely impact health:

·      Participation and representation by civil society, health actors, and marginalized groups are insufficient in decision-making

·      Difficult to hold actors accountable due to inadequate means to constrain power and poor transparency

·      Norms, rules, and decision-making procedures are often impervious to changing needs and typically sustain entrenched power disparities

·      Inadequate means at national and global levels to protect health in policymaking arenas outside of the health sector

·      Total or near absence of institutions (treaties, courts, funds) or norms to protect and promote health.

The Commission highlights that global health inequities are not a natural phenomenon but the result of poor social policies and programs, unfair economic arrangements, and bad politics.

The Commission proposes three steps to begin addressing the global political determinants of health:

·      Multi-stakeholder platform on governance for health to frame issues, set agendas, and debate policies

·      Independent monitoring of how global governance processes affect health equity through an independent scientific monitoring panel

·      Strengthened use of human rights instruments and stronger sanctions against violations

The Health in All Policies approach promotes the consideration of population health equity in every type of policy decision in every type of organization.

Pepin D, Winig BD, Carr D, Jacobson PD. Collaborating for health: health in all policies and the law. The Journal of Law, Medicine & Ethics. 2017;45(1). 

Health in All Policies. Colorado Association of Local Public Health Officials.

Health in all Policies efforts include collaboration across all sectors impacting health, engaging community groups and a broad set of stakeholders.

The Colorado Association of Local Public Health Officials notes that health in all policies may not always be the right frame to use; those in the health sector should recognize other sectors’ priorities.