The Political Determinants of Health
Daniel E. Dawes
Johns Hopkins University Press
2020
In thinking about the determinants of health, we usually do not consider politics to be an important factor. In his current book, The Political Determinants of Health, Dawes notes that although life expectancy has increased by thirty years in the United States, only five of those years were attributable to better health access and higher quality care. The other twenty-five years of increased life expectancy are due to non-health care factors; these are dominated by political control.
At present, the United States’ rank in health care is deplorable. Although the United States’ healthcare expenditure is the highest in the world, the United States ranks 43rd in life expectancy. Dawes begins this book with an interesting parable of a farmer growing an orchard. His analogy concludes that in health care we have emphasized equality at the expense of equity. Equity is rooted in the principle of distributive justice. It means that there must be a concern with the apportionment of privileges, duties, and goods in consonance with the merits of the individual and in the best interest of society. The author’s plea is that there must be a focus on the social, economic, behavioral health, and environmental determinants of health.
The political determinants of health are voting, government and policy. Voting is the first factor because who we choose to make the big decisions is crucial. Yet it is unusual to have more than 50% of registered voters vote in any election. Government is the mechanism for determining policy. The government includes the courts as well as the legislature. Our Supreme Court has had a significantly negative history with regard to health care decisions. Policy controls what is done. It seeks to achieve specific goals. It outlines priorities and defines expected roles. Policy builds consensus and keeps people informed.
The author then inserts two long chapters on President Obama’s Patient Protection and Affordable Care Act. This act serves as Dawes’ prime example of how Democratic presidents usually have a more positive effect on health policy than Republican presidents.
He has a brilliant conclusion in the final chapter with this statement: “Today’s poor health outcomes, lower life expectancy, and health inequities in the United States and in other countries did not happen overnight but was the result of compounding intentional political determinants. For too many countries, the political determinants of health inequities have triumphed over the political determinants of health.”
This is an important book. The social determinants of health must be emphasized. If our health care system is going to be positively changed, we must understand what factors are really important. This book will force you and our leaders to rethink the role of social, environmental, economic, and other factors in what will be best for our patients and our country.
