Safe and Accessible Voting: The Role of Public Health

More than any other factor, our health is determined by the physical, social, cultural, and economic environments in which we live. Recognizing this, as far back as 1988, the Institute of Medicine (IOM; now called the National Academy of Medicine) challenged public health professionals to “collectively” take on the task of “assuring the conditions in which people can be healthy.”¹ Public health professionals widely agree, and for more than 30 years, we have been asking and reasking ourselves: How do we do that?

In answering that question, we too often slip into public health jargon, including “social determinants of health,” “health impact pyramids,” and “policy, system, and environmental change strategies.” These terms are useful in their place, but they are too abstract, academic, and bureaucratic to effectively communicate with the public and generate meaningful change. A more pragmatic and effective approach would focus on action, and a good place to start is with voting. As public health professionals, we must embrace our civic role by voting, doing everything in our power to encourage all eligible people to vote, and, during the COVID-19 pandemic, making certain voting is safe for everyone.

Voting strengthens democracy and enhances health by giving people a role in the policy processes that affect all social determinants of health. Policy formation starts with a perception of the public will and is primarily shaped by voting results. From there, policy formation goes on to affect services, systems, and environments at all levels of the health impact pyramid in every community. The evidence is clear: civic engagement, particularly through voting, is one of the greatest influencers of public policy.

Multiple studies confirm the health consequences of voting. This manifests in two distinct ways. First, voting helps decide political leadership. When more people vote, leaders have an increased incentive to address the needs of communities (including health needs) that they might otherwise have ignored. Second, voting itself, as an act of civic engagement, supports health on an individual level. One study, conducted across 44 countries, showed that voter participation was associated with better self-reported health (https://bit.ly/2IDNVAN).² Another study showed that those who did not vote reported poorer health outcomes. The 10 least healthy US states have a voting participation rate nearly 10 percentage points lower than the 10 healthiest states.³ Research also shows that social, economic, and health inequities have a large effect on electoral participation.⁴

History also records the impact of suffrage on health. Although multiple factors played a role, it was after women got the right to vote in 1920 that the maternal and infant mortality rates dropped dramatically.⁵ This can be attributed greatly to the passage of the Sheppard-Towner Act of 1921, which set up maternal and child health units in every state health department, expanded collection of birth and death data, supported home-visiting initiatives, and began federal funding of state health programs. Similarly, when the Voting Rights Act of 1965 passed, infant mortality rates again dropped and the Black–White disparity in those rates narrowed, attributable to the legislation that was passed in response to new voter enfranchisement (https://bit.ly/3505tOQ).⁶ In both cases, policies responded to the needs of the people when previously disenfranchised people expressed their will by voting. What landmark pieces of legislation have we never even imagined because nearly 40% of people do not vote?

Although everyone should be engaged in increasing voter participation (part of the collective action the IOM has identified to improve living conditions), public health professionals are in a unique position to promote civic engagement in a safe and nonpartisan way that enhances health and builds democracy. This year, when gatherings pose a risk to health, the public health work on voting takes on a distinct urgency and importance. Our job is twofold: we must guarantee that all voting can be done safely, and we must simultaneously work to ensure that everyone who can vote does so. Because public health professionals often work directly with populations that have frequently experienced voter suppression efforts, it is well within public health’s mission to help people in these communities vote and to work to remove the systemic barriers that prevent or discourage people from voting. Increasing civic participation is an essential task for anyone interested in advancing health equity, and part of the job of a public health worker is to help make that happen.

From a voter safety perspective, there are many potential options to carry out this mission, especially during COVID-19, including voting by mail, voting early, increasing the number of polling sites, and observing social-distancing measures when voting in person. In every state, there are many initiatives promoting voting that could benefit from the involvement of public health. One effort is We Can Vote (https://wecanvote.us), which is working to elevate voting as a public health issue. Another example is the organization VotER (https://vot-er.org)—established to bring together a team of physicians, designers, and behavioral scientists—which offers patients the chance to register to vote while with a medical provider in a nonpartisan, noninterruptive, and completely optional way. Public health organizations such as the American Public Health Association, the Association of State and Territorial Health Officials, and the National Association of County and City Health Officials are implementing a similar program, called VoteSafe, for the public health community. Public health workers should review the options available in their state, publicize the information to the public, and lend their influence in promoting healthy voting.

In addition, many in public health philanthropy are rallying their resources to support civic participation. The Langeloth Foundation (where we are board members), for example, recently granted $20 million to organizations supporting civic engagement and participation efforts, including the nonpartisan State Infrastructure Fund (https://bit.ly/3nP18GO) and the Heartland Fund (https://bit.ly/33ZubQe). This was more than 20% of Langeloth’s $88 million endowment. These intermediaries support a network of on-the-ground voter engagement and civic participation organizations in several states. With traditional voter engagement activities upended by the COVID-19 pandemic, the State Infrastructure Fund and the Heartland Fund have supported organizations that now have to pivot to remote and digital organizing strategies and tactics.

Our country is in the midst of cascading and interconnected crises: an infectious disease pandemic, nationwide protests against racial injustice, and catastrophic economic strain for millions of people. Each of these crises reveals the deficiencies and inadequacies of our health, social, and economic systems and the need for significant policy changes to address the flaws. With a major election already under way, it is more important than ever that all of our citizens have their voices heard. This is essential not just for the health of our democracy but for the health of individuals and communities. The consequences of the election will last far beyond November 3, 2020 and will be seen in the decisions of policymakers for years to come. Likewise, the efforts made to increase voting participation, security, and safety will positively affect civic engagement in future elections. There is no time to lose. All hands are needed to elevate voting as an essential tool for improving public health. Public health workers must become part of the broad-based effort to get out the vote and to ensure that voting is safe for everyone.