Politics and Public Health.

Speaking to a group of students during the run-up to the 2004 presidential election, the late journalist Molly Ivins made an impassioned case for the day-to-day relevance of politics. She said, “We live our lives surrounded by a nest of law and regulation…. The qualifications of the people who prescribe your eyeglasses, whether or not the lady who dyes your hair knows what she’s doing, how deep you will be buried when you die … the books your children will read in schools … all of those are consequences of a political decision.” I agree, and would stress, in particular, the role of politics as a macrosocial determinant of health. Politics shapes the social, economic, and environmental conditions that, in turn, shape the health of populations. From monetary policy, to pollution control, to the appointment of judges who decide the great civil rights cases of our time, politics is integral to the safety and well-being of many millions. While this is true every day, the context of the election next month makes the point all the more necessary to affirm. A note, then, on the importance of politics, and a look at how elections influence health, in ways big and small, beginning with two examples from the past.

History teaches us that the outcome of a single election can have profound, generation-defining consequences, and that these consequences can depend on the slimmest of margins. Take, for example, the election of 1876, between Republican Rutherford B. Hayes and Democrat Samuel J. Tilden. The Reconstruction-era race was to succeed President Ulysses S. Grant, the former Civil War commander who, as president, worked to protect the rights of newly freed slaves by using military force against the nascent Ku Klux Klan and supporting the Fifteenth Amendment. Like Grant, Hayes was a Republican—the party of Lincoln, and, at the time, the party enforcing the policies of Reconstruction in the South. The 1876 election results were too close to call—Tilden had 4,284,020 votes to Hayes’s 4,036,572, with 20 remaining electoral votes in dispute amidst allegations of fraud. After months of controversy, a backroom deal was struck: Democrats would agree to a Hayes presidency, if Hayes would agree to remove federal troops from the South, effectively ceding power to segregationist southern legislatures and abandoning the black population to nearly a century of institutional racism in the form of Jim Crow. We live with the effects of this election to this day. Given all we know about how racism can undermine health, its corrosive effect on communities, and the damage it can do when it is codified into law at the political level, it is difficult not to wonder how less sick we would be had some of the more progressive, racially egalitarian policies of Reconstruction been allowed to continue. When we grapple with the legacy of segregation and bigotry in the US, and the health consequences of these conditions, we are, in part, grappling with the legacy of the election of 1876. And it all came down to 20 electoral votes.

Just as elections can deepen and codify injustice, they can also be instrumental in advancing progress. In the presidential election of 1964, for example, the incumbent Lyndon Baines Johnson won a landslide victory over Senator Barry Goldwater. Johnson carried 44 states, to Goldwater’s 6. Following the assassination of President John F. Kennedy, Johnson had spent the remainder of his predecessor’s term fighting to pass the most comprehensive civil rights bill in the country’s history. His overwhelming victory over Goldwater gave him a mandate to continue advocating for bold domestic legislation, enabled by a two-thirds majority for his Democratic party in both houses of Congress. In the end, Congress would pass close to 200 pieces of major legislation put forward by Johnson, including Medicare, Medicaid, and the Voting Rights Act of 1965. LBJ called his program of reform the Great Society. While his domestic achievements would soon be overshadowed by civil unrest and the escalating war in Vietnam, Johnson’s legislative momentum in the years after the 1964 election continues to have a far-reaching effect on American life and health. While Medicare and Medicaid are perhaps the two Great Society measures most explicitly linked to health, the initiative’s focus on poverty, education, urban renewal, and the environment represents an ambitious attempt to engage with the fundamental determinants of well-being in populations, and to lift up the poor and the marginalized, with an eye towards advancing social justice. In 1964, Americans were given a chance to pass judgment on LBJ’s earlier push for a fairer society through the Civil Rights Act of 1964. Their resounding approval let Johnson proceed with his domestic ambitions, creating, in the process, the template for a more socially involved, activist federal government.

While the upcoming election may not lead to a legislative program that matches the Great Society in scope, our current candidates both stand to influence our country in very different ways. This is particularly true in the case of health. A look, first, at the health positions of Donald Trump. Because Trump has sometimes reversed his opinions in interviews and on the stump, I will engage with his positions as stated on his campaign website. Trump, like many Republicans, has pledged to repeal the Affordable Care Act, calling it an “incredible economic burden.” I have previously written in this space about the benefits that have accrued to our country’s health thanks to the Affordable Care Act’s introduction. At the same time, Trump has said he will “broaden healthcare access, make healthcare more affordable and improve the quality of care available to all Americans.” For Trump, this means allowing vendors to sell health insurance across state lines, allowing taxpayers to deduct health insurance premiums from their returns, and requiring health care price transparency from providers, among other measures. Trump has cited the cost of providing health care to illegal immigrants as an $11 billion drag on the health system, and claimed that stricter enforcement of immigration laws could “relieve healthcare cost pressures on state and local governments.” He has also stressed the role of economics as a determinant of health, saying “the best social program has always been a job—and taking care of our economy will go a long way towards reducing our dependence on public health programs.” While this does not address the fundamental role of economic inequality in shaping health, it is at least an acknowledgement of a key foundational driver of health, and suggests a health policy that would look beyond an investment in treatment alone.

Having said this, it is important to add that Trump’s long record of misogyny and racism, his embrace of violence at campaign events, and his statements supporting war crimes like torture are, at best, a contradiction and, at worst, an outright negation of any good intentions he may have in the area of health policy. I have written before about the health consequences of racism, gender inequity, hate, and war—any political initiative, however ambitious, will not be enough to offset the harm these conditions can cause if left unchecked, or, especially, if endorsed by the President of the United States.

Given Hillary Clinton’s efforts for universal health care during Bill Clinton’s presidency, it is perhaps to be expected that her position on the Affordable Care Act is very different than her opponent’s. She has expressed her intention to “defend and expand” the ACA by working towards a “public option” and allowing individuals over the age of 55 to buy into Medicare. By incentivizing states to expand Medicaid, she has said she will work to bring health insurance to less economically advantaged Americans. Like Trump, Clinton has decried the high price of prescription drugs. Her plan to lower costs would require pharmaceutical companies receiving taxpayer support to reroute investment away from marketing and profits and into research. Her policies also address health equity. This entails a commitment to defending the right of women to access contraception, preventative care, and safe abortion, as well as expanding health access to rural Americans and immigrant families. She has also pledged to double funding for community health centers.

In the aftermath of last summer’s “Brexit” referendum in the UK, some of the Leave supporters expressed surprise that their vote ultimately carried the day. One said, “I’m shocked that we actually voted to leave. I didn’t think that was going to happen. My vote, I didn’t think, was going to matter too much because I thought we were just going to remain.” Voters in the US expressed similar doubts about the power of their vote to affect the outcome of the presidential primaries. Supporters of both Bernie Sanders and Donald Trump protested what they saw as a “rigged” system. While this view may be understandable, especially in the testy context of a campaign season, it would be a shame if it led anyone to withdraw from the political process. We have a responsibility to remain engaged in the workings of a very foundational determinant of health: politics. This is very much in keeping with our values as a school—from Professor David Rosenbloom’s work here in Boston with the administrations of Mayors Kevin White and Martin Walsh, to Professor Wendy Mariner’s analysis of the implementation of the Affordable Care Act, to the political leaders we invite to our campus, to our mock election last spring.

I hope everyone has a terrific week. Until next week.

Warm regards,

Sandro

Sandro Galea, MD, DrPH
Dean and Robert A. Knox Professor
Boston University School of Public Health
Twitter: @sandrogalea

Acknowledgement: I am grateful to Eric DelGizzo for his contributions to this Dean’s Note.

Previous Dean’s Notes are archived at: https://www.bu.edu/sph/tag/deans-note/