Social injustice as a common source epidemic: the role of civic engagement in addressing inequitable population health

The United States surpassed 1.1 million deaths due to the coronavirus disease 2019 (COVID-19) by the end of 2022. Observed patterns across the country indicate the COVID-19 pandemic occurs within a highly complex, multifactorial syndemic context with social injustice serving as a common source of the epidemic.^1,2 Social circumstances and underlying social injustices are reflected in significantly higher rates of COVID-19 mortality and chronic diseases among the most oppressed racial/ethnic subpopulations.²

Social injustice, when considered as the underlying common source epidemic, occurs at least in part, as the result of laws, policies, and regulations that carry unfair and unjust practices into society. Such policies and practices are related to poverty, low-wage jobs, lack of access to health care and insurance, among other social drivers of health and well-being that collectively determine an estimated 30–50% of population health outcomes.³

Access to voting as a metric of civic engagement

We posit that when civic engagement is increased people and communities are healthier. To illustrate support for this contention, Fig. 1 shows the relationship between an index of 12 public health outcomes and access to voting.⁴ States that make elections more accessible through policies such as same-day registration, options to vote by mail, or felon re-enfranchisement, tend to experience higher levels of voter participation and show stronger public health outcomes. Basically, when “voting access” is considered as a metric of civic engagement, less voting access is related to worse health outcomes whereas more voting access is related to better health outcomes.^4,5 Civic and voter participation also shows strong associations with health disparities.⁵ Hence, civic participation and engagement in the form of voting reflects a level of participation in democracy that has the potential to impact on ways in which (public) resources are applied to improve the health, well-being, and prosperity of people.

Fig. 1.

Health & Democracy Index illustrating the relationship between access to voting and public health outcomes across the United States. Comparison of 12 public health indicators and voter turnout to the restrictiveness of voting access in each state based on the Health & Democracy Index.⁴ Overall, states with more inclusive voting policies and greater levels of civic participation are healthier. States with exclusionary voting laws, more barriers to voting, and lower rates of voter participation have worse public health outcomes (From: Healthy Democracy Healthy People⁴; used with permission).

Call to action for the health sector

The health sector can play a critical role in promoting inclusive democratic practices. Several action steps are necessary to strengthen civic and voter participation to advance health equity and population health outcomes. The steps we propose align with efforts to promote the health and well-being of citizens of the United States⁶ by first establishing “increasing the proportion of the voting-age citizens who vote” as a core objective within Healthy People 2030. Currently, this is a research objective (i.e., SDOH-R02) but moving it to become a core objective will ensure that: 1) The measure will have an identified data source; 2) a baseline will be available; 3) at least one additional data point will be collected throughout the decade; and 4) evidence-based interventions are available. The measure reflects civic engagement and represents the Healthy People 2030 framework component of “cultivating healthier social, physical, and economic environments.⁶”

Second, the Department of Health and Human Services (DHHS) and the Office of Disease Prevention and Health Promotion (ODPHP), which coordinates the Healthy People initiative, should support the development, data collection, and ongoing reporting of this metric throughout the decade. ODPHP should conduct or commission systematic reviews on the impact of voting-related interventions on health-related outcomes and the reduction or elimination of health disparities. Results of the systematic reviews should be translated into guidance for local, state, tribal, and federal efforts. Evidence gaps should be highlighted and prioritised for funding.

Third, DHHS should provide specific guidance to agencies and institutions receiving federal funding on what actions and efforts to implement that can promote civic engagement and increase voter participation. Funding agencies should increase research support that connects civic engagement and voting access to equitable population health outcomes. States should be encouraged to apply for federal funding to support implementation of evidence-based programs, policies, and systems at the community level. A line-of-sight should be created that connects voting-related factors (increased rate of voting, increased access to voting, etc.) to changes in social cohesion, community dialogue, and accountability that leads to new or revised laws, policies, or regulations.

Conclusions

Prevalence of lifestyle behaviours, health risk factors, chronic conditions, COVID–19 mortality, and social drivers of health indicate an unequal population health burden that exists along racial/ethnic lines.1, 2, 3, 4, 5 An underlying epidemic of social injustice is linked to civic engagement and public health outcomes (see Fig. 1).³ Laws and policies should be considered as foci for interventions that increase civic engagement.⁷ Increasing the proportion of the voting-age citizens who vote would be a specific objective to increase civic engagement. A focus on engagement in democracy may prompt the changes we need to achieve health equity, improve population health, and enhance well-being for all.

Contributors

N.P.P. wrote the first draft. R.A.A. edited and provided revisions on draft versions. J.F.A. created Fig. 1 and provided edits and revisions on draft versions.

Declaration of interests

N.P.P. is paid a salary by HealthPartners. R.A.A. declares no competing interests. J.F.A. is paid consulting fees to serve as Executive Director of Healthy Democracy Healthy People.