We Need to Talk About the Political Determinants of Health
Photo by Jason Leung on Unsplash
It's become relatively common within public health conversations to hear the term "social determinants of health." The widespread adoption and acceptance of social determinants is encouraging, especially considering the outsized impact that our social and built environments have on health outcomes. In my work in helping lead and develop social impact projects that often intersect with public health, I often come across and collaborate with people who are acutely aware that the health of the individual and the health of a community are intertwined.
However, what I have discovered is that few seem to be aware of the political determinants of health— those factors and causes that lie further upstream than social determinants. Even among those who understand that all social determinants of health have political origin points, there seems to be a general reluctance to call attention to the ways that policies and governmental choices have a profound influence on public health outcomes, including outcomes that involve avoidable harm and premature death.
This reluctance may have an understandable cause— a desire to avoid retaliation or unemployment for saying something those who hold power would rather not hear, for example. But mostly, I find that people involved in public health and making health policy are unaware of the political determinants of health.
This needs to change.
Going Further Upstream
In the United States, your zip code is a more accurate predictor of your overall health than your genetic code. How did your zip code come to be a better predictor of health outcomes than hereditary factors? The answer involves understanding not just social determinants of health, but what creates them in the first place.
Most people familiar with public health understand that social determinants of health (SDH) refer to "the conditions in which people are born, grow, live, work and age, and people's access to power, money and resources"—essentially anything non-medical that serves as the basis for health outcomes. What's crucial to understand is that 70% of our health outcomes result from these social determinants.
But here's the critical question: Where do the social determinants of health come from?
The metaphor of a river is helpful for thinking about cause and effect. The concept of "upstreaming" comes from Desmond Tutu's oft-cited quote: "There comes a point where we need to stop just pulling people out of the river. We need to go upstream and find out why they're falling in."
Once we've gone upstream far enough to discover why people are falling in, we can go even further to determine what created the conditions that led to people falling—or being thrown—in. Political determinants of health are these conditions that lie further upstream and are the cause of the social determinants of health.
The term was coined by Daniel Dawes, who wrote a book of the same name in 2020. Political determinants of health refer to the political climates and decisions that "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."
Every social condition that benefits or harms individual and community health can be traced back to a political origin point: people who made collective decisions; voters who vote for or against candidates or referendums; officials who make decisions or withhold actions that benefit some and harm others, that adhere to one ideology but purposefully avoid others; policies shaped by special interests and filtered through cultural realities; institutions and other organizations that lobby and stall, advocate and challenge.
Consider, for example, the elevated risk of asthma among children in urban areas. Through the framing of social determinants of health, we can connect that living near high-traffic areas produces higher levels of localized air pollution, which causes asthma. But examining this through political determinants raises more foundational questions: Why was this interstate placed through these communities? What steps have been taken to lower harmful emissions? What policies minimize the harm of air pollution and offer assistance to those impacted by their environment?
The Current Crisis is Real and Unprecedented
To be clear, the political in political determinants of health doesn't inherently refer to left-right perspectives or any particular political ideology. Political determinants have existed since the invention of society and government. However, anyone paying attention to American politics shouldn't need an explanation when I say that our public health system is facing a crisis of unprecedented proportions in the modern era. At the federal level, public health funding and talent are being hollowed out, redistributed to accounts and purposes unknown. This loss of funding will be difficult, if not impossible, to replace at the state level, assuming your state is interested in making up the loss (many are not).
The loss of public health funding and talent represents a political determinant of the current health crisis. The decisions being made in response to this collapse in funding and personnel constitute another crisis as well.
Take my home state of Indiana. The state recently announced that childcare reimbursement rates would be slashed 10-35%. This reduction will undoubtedly prevent many parents from affording quality childcare from licensed providers. As a result, we can expect more parents, desperate for childcare in order to work, to rely upon informal and often substandard childcare options, including unlicensed and unqualified daycare facilities. In 2024, responding to Indiana's childcare crisis, the state legislature increased the number of children unlicensed daycares were allowed to watch from 6 to 8. This recent move to lower reimbursement rates will only send more children to unlicensed facilities. Historically, when children are killed, abused, or significantly injured while in daycare, this harm is overwhelmingly likely to occur at unlicensed facilities. If history is any guide, Hoosier children will die because of these reimbursement reductions, and these deaths are almost certainly preventable.
We have reached a point in American society where public health outcomes have begun to diverge along a red-blue divide, and all evidence suggests this division will only accelerate. Partisan-based health outcomes, which began in earnest during COVID when red states saw more COVID infections and deaths than blue states, have become increasingly normalized. One would think that people who live in red states would begin to openly wonder why they and their children’s lives are being cut short by bad political decisions, but that does not yet seem to be happening.
When the CDC began cutting grants under the current Trump administration, blue states and cities sued for the return of funding. Red states did not. As a result, blue states have recovered nearly all of the promised and allocated funding, whereas red states have lost all of their funding. The reasons for this loss are entirely political and could have been avoided had GOP leaders in red states simply challenged the Trump administration. Instead, political leadership in these states were willing to watch funding for public health disappear rather than advocate for the residents who directly elected them. Life expectancy disparities between red and blue states, already diverging and becoming increasingly longer in blue states, will most likely only accelerate.
The reality is this: we won't know the full impact of today's political decisions on our overall public health for generations to come, but we know it will be bad. Consider that the social determinants of health due to redlining—a policy that offically started in 1933—can reasonably be expected to continue shaping lives and futures for another 100 years. The outcomes of today's decisions will be felt and measured across centuries.
Political climate itself is a contributing factor in the political determinants of health. Already, I see public health officials in Indiana, aware they are becoming increasingly subjected to scrutiny and disdain by conservative political elites, avoiding any behavior or outspokenness that would draw additional unwanted attention. Instead, often as a means of survival, they try to lay low, remain focused on their jobs despite dwindling resources and social support, and do what they can with what they have available. Paradoxically, those who should be the loudest and leading the conversation about the political determinants of health are most likely to face censorship and retribution for speaking honestly about drivers of disease and poor health outcomes.
Awareness Without Hopelessness
What I'm saying doesn't seem very hopeful. This feeling of hopelessness might indicate you've interpreted the situation accurately. My argument is essentially that "choices have consequences"—not a radical concept. Choices have been made, and there will be consequences. To suggest otherwise would be Pollyannaish.
But hopelessness without end feeds the beast of inaction. It makes for a lousy strategy.
While we likely won't be able to prevent most seriously negative health outcomes that will arrive as a result of political decisions made today (unless, by some miracle, funding is restored and exponentially increased), there are reasons to feel hopeful and, more importantly, reasons to take action.
Here's what we need to do: start talking a lot more about the political determinants of health. While social determinants of health have become a mainstay in public health, far too few people are aware of, let alone discussing, the political causes of the social conditions that determine a majority of health outcomes. This is always a serious problem, but it's far more urgent during a time of extreme and harmful political determinants of health.
For those who do not feel at risk for retribution or loss of employment for speaking out, we need to provide cover for public health officials— the vast majority who are simply trying to their jobs as best they can— and ask the uncomfortable questions of elected leaders whenever and whereever we can.
”Whose lives will be impacted by your decision?”
”Whose lives deserve to be cut short?”
”How many premature deaths are acceptable?”
”Who will pay for the additonal long term expenses this policy will impose?”
”Whose children deserve to be sicker, poorer, or struggling?”
These questions help bring the moral contours of policy and governance back into focus. They emphasize and demand accountability for tomorrow’s consequences of today’s actions. And, best of all, they can be asked of anyone involved in government or related to public health, local or otherwise.
PDH should be understood in ways similar to SDH: as evidence-based leading and early indicators and predictors of population-level health outcomes. When more people are aware of PDH, it becomes possible to push this narrative into the mainstream and collaborate around collective strategies for achieving new and beneficial political determinants of health.
Maybe the most important actions you can take for public health right now are to first read up on political determinants of health and then begin using and sharing this terminology. Once we name the idea and map the concept, we can begin to develop and enact our own political determinants of health.
Hope, after all, is a consequence of choosing action and strategy. There will be more to come on what that action and strategy might look like—because this crisis, as unprecedented as it is, is also a moment of opportunity. But for now, perhaps the most immediate way forward is to encourage the broad adoption and use of the term political determinants of health.