The Political Determinants of Health

Book Title: The Political Determinants of Health

Author: Daniel E. Dawes

Publication Information: Baltimore, MD, Johns Hopkins University Press, 2020, 216 pp., $29.95, paperback

It has become commonplace in health professions education to teach about the social determinants of health, defined as “the conditions under which people are born, grow, live, work, and age.”¹ Social determinants such as economic status, education, employment, and support networks have a far greater impact on individual and population health than biology, behavior, and health care. These social determinants are influenced by structural determinants, rules and policies that are “constructed” through deliberate actions and enforced sometimes by custom, but more commonly through legislation. One of the first uses in the medical literature of the term “political determinants of health” was in 2005 by Professor Ilona Kickbusch, who contended that “the crisis in global health is not a crisis of disease, it is a crisis of governance.”² More recently, Dr Ranit Mishori argued that US medical schools “should be engaging in open and robust discussions of how politicians and politics affect and shape our patients’ lives, our communities, and the [social determinants] themselves.”³ Now Daniel Dawes, director of the Satcher Health Leadership Institute at Morehouse School of Medicine, has written the first book-length exposition, The Political Determinants of Health. A former Congressional staffer and attorney, Dawes led a working group of more than 300 organizations advocating for health equity provisions in the Affordable Care Act (ACA).

Readers expecting to plunge into a discussion of health policy may be surprised by the book’s introductory chapter, “The Allegory of the Orchard,” about a farmer who plants several trees in soil of varying quality and nurtures each one unequally, lavishing attention on the trees that he believes are most likely to bear fruit. Dawes explains how this story is an allegory for health inequities in the United States, with the soil representing housing and fertilizer representing education. The next chapter discusses specific historical policies that either preserved or mitigated the unequal distribution of wealth and health, from the failure to abolish slavery prior to the Civil War to the creation and dissolution of the Freedman’s Bureau that fed, educated, and protected the political rights of newly freed persons during the Reconstruction era. Dawes recounts several failed 20th-century attempts to pass legislation on national health insurance that were intertwined with more successful efforts to secure civil rights for African Americans and medical care and community services for persons with mental health conditions.

Dawes then takes readers on a detour, devoting the third chapter to describing a detailed conceptual model of the political determinants of health. This model highlights the contributing factors and interactions between voting, government, and policy. Among other illustrative examples, Dawes criticizes recent decisions of the US Supreme Court to invalidate voting protections for racial minorities based on the false premise that “vestiges of legally sanctioned discrimination” no longer prevent marginalized communities from participating fully in the electoral process (p. 63).

The remaining chapters narrate the efforts of Dawes and others to marshal long-frustrated health equity advocates to take advantage of President Barack Obama’s election and Democratic Congressional majorities to pass the ACA in 2010 and to defend it from subsequent threats. Although the ACA’s scope was gradually narrowed from “comprehensive health reform” to “health care reform” to “health insurance reform” (pp. 110-111), Dawes’s working group successfully protected key provisions charging federal agencies to routinely collect data about health disparities and to promote policies to reduce these disparities. The 2016 election of President Donald Trump, who promised to repeal the ACA, underlined the importance of voting as a political determinant of health; although Congress was unable to pass “repeal and replace” legislation during his term, a host of executive actions reversed the previously-rising percentage of Americans with comprehensive health insurance.

Political Determinants of Health should be commended for packing an immense amount of theory, history, and health advocacy into a relatively concise text. However, the audience for this book is unclear. Those seeking a political history of the ACA would be better served by reading other works with broader perspectives.^4,5 Medical students or residents interested in health advocacy may get bogged down in the book’s legislative details, while experienced physician educators and advocates may view the orchard allegory and conceptual model to be distracting or unnecessary. Although Dawes finished this book prior to the COVID-19 pandemic, George Floyd’s murder and demonstrations for racial justice, and the 2020 election and disinformation campaign about who won, these recent cataclysms confirm its basic premise that politics and policies, by creating the structures that shape social determinants, have enduring effects on our patients’ health outcomes.