Voting is a Health Issue

In addition to the standard inquiries about illnesses, vaccinations, diet, and behavior, somewhere in the series of well-child visits I would always ask the parents of my patients four additional questions. Does your child know how to swim? Does everyone in your family have a library card? Have you taken your child(ren) to visit the state capitol? Are you registered to vote? (Although I’m no longer in clinical practice, I still ask those questions of my neighbors and friends with young children.) Parents intuitively understood that swimming was a life-saving skill and quickly grasped the link between reading and educational success and health. But they were usually perplexed and intrigued by the last two questions. They were surprised to discover that the policy decisions made at the state capitol (and at all levels of government) had a bigger impact on their child’s health than the medical care they received. Once they understood that, it was easy to convince them that voting was one of the best ways to influence those decisions. I always made information on how to register to vote available to parents as part of the “anticipatory guidance” portion of the well-child visit. In my various public health roles, I have continued similar discussions about what determines health. Most people are astonished to learn that medical care accounts for only 10%-20% of society’s overall health while at least 50% of health is determined by the social, economic, and environmental conditions1 in their communities, i.e., the social determinants of health that are influenced by policy decisions at all levels of government. Like my former patients, once people recognize that fact, they better understand why voting is a public health issue. The American Medical Association has also recently recognized that by acknowledging voting as a social determinant of health.2 Multiple studies confirm the health consequences of voting. Where voting participation is high, the population’s health is better.3 The 10 least healthy states in America have voting participation rates nearly 10 percentage points lower than the 10 healthiest states.4 Recent analyses of state voting policies by Healthy Democracy/Healthy People demonstrate that states with more inclusive voting policies have a higher level of health.5 The easier it is to vote, the healthier the population. History also demonstrates the impact of voting on health—particularly the health of mothers and babies. After women gained the right to vote in 1920 maternal and infant mortality rates dropped precipitously.6 Among other things, this can be attributed to the passage of the Sheppard Towner Act of 1921, which set up maternal and child health (MCH) units in every state health department, expanded collection of birth and death data, and began federal funding of state MCH programs. Similarly, when many of the racially-based barriers to voting were eliminated by the passage of the Voting Rights Act of 1965, infant mortality rates again dropped and the Black/white disparity narrowed.7 In both situations, policy makers began to address the needs of previously disenfranchised people only when they were able to express their will by voting. In this election year, like that of 2020, our country is in the midst of interconnected crises: an infectious disease pandemic, nationwide struggles to confront racial injustice, and economic hardships affecting millions. Each of these crises reveals the deficiencies and inadequacies of our health, social, and economic systems, and the urgent need for significant policy changes to address the flaws. When you add to that the crisis caused by the overturning of Roe v Wade, the importance of voting gets further magnified. Officials elected in November will be the people with the

The lessons of 1920 and 1965 teach us that universal suffrage is essential not just for the health of our democracy, but for the physical and mental health of individuals and communities.

opportunity to craft policy changes to address all these issues. Thus, it is important that all our citizens have their voices heard — particularly those who have been disenfranchised in the past. The lessons of 1920 and 1965 teach us that universal suffrage is essential not just for the health of our democracy, but for the physical and mental health of individuals and communities. While everyone should be engaged in increasing voter participation, healthcare and public health professionals are in a unique position to promote in a non-partisan way the civic engagement necessary to enhance health and build democracy. Since many healthcare and public health professionals work directly with populations that have frequently experienced voter suppression, it is well within their purview to encourage people in these communities to vote and to advocate for the removal of the systemic barriers that prevent or discourage them from voting. Increasing civic participation is an essential task for anyone interested in advancing health and health equity. Part of our clinical and public health roles is to help make that happen. As a parent, grandparent, and pediatrician, I recognize that raising a healthy child is a difficult task. I’ve also learned that no parent can do it alone. It is a tired, overused, but accurate cliché that “it takes a village to raise a child.” What is not well recognized is that part of that village’s role is to encourage every adult to vote. A village of voters is necessary to create the conditions in which every child and every adult has the opportunity to be healthy and thrive. As the November election nears, now is the time for everyone in every village to step forward and vote. We can help make that happen by facilitating voter registration and encouraging voting among our family, friends, neighbors, and patients. It is the most powerful thing we can do for the health and well-being of ourselves, our children, and our community.

Edward P. Ehlinger, MD, MSPH, is a former State Health Official from Minnesota and past president of the Association of State and Territorial Health Officials (ASTHO), TCMS, and the Minnesota Public Health Association. He is the acting chair of the HHS Secretary’s Advisory Committee on Infant and Maternal Mortality, provides coaching for the National Leadership Academy for the Public’s Health, and advocates for public health, social justice, and community-building initiatives locally and nationally. For over 50 years he has been working to socialize an alternative narrative to the dominant one about what creates health—especially the health of mothers and infants. The story he tells most often is Abiyoyo, which is based on a South African lullabye and folk story.

(Endnotes) 1. Tarlov AR. Public policy frameworks for improving population health. Ann NY Acad Sci 1999; 896; 281-93. 2. https://www.medpagetoday.com/meetingcoverage/ama/99223. 3. Kim S, Kim CY, You MS. Civic participation and self-rated health: a cross-national multi-level analysis using the world value survey. J Prev

Med Public Health. 2015;48(1):18–27. 4. https://www.americashealthrankings.org/ https://ballotpedia.org/Voter_turnout_in_United_States_elections. 5. https://www.healthydemocracyhealthypeople. org/. 6. Achievements in Public Health, 1900-1999:

Healthier Mothers and Babies, MMWR, October 01, 1999 / 48(38);849-858. 7. https://economics.yale.edu/sites/default/files/ files/Workshops-Seminars/Economic-History/ thomasson-011011.pdf.