Health Equity Leader says Political Policies Created Poor Health in the U.S., and Only New Policies Can Undo the Damage and Improve Health

ST. JOSEPH, Mich.—In city after city across the United States, it is no accident that major highways cut through communities of color. Or that these communities are disproportionately riddled with polluting factories and contain more bus stops and railroads than other, more prosperous, whiter communities. Or that residents often find themselves far from grocery stores with fresh fruits and vegetables.

Daniel Dawes, who heads the Satcher Health Leadership Institute at the Morehouse School of Medicine in Atlanta, says these so-called social determinants of health, or SDoH, are not natural, “organic” developments. They stem from intentionally discriminatory policies created and perpetuated over centuries, from the federal level all the way down to the very local level, where policy “with a small ‘p’” prevails. And these policies have led to health inequities, notably the early onset of serious diseases and premature deaths, in racially and ethnically marginalized communities.

Dawes, a national leader in health equity, takes a new approach. He labels the policies that create living conditions the political determinants of health. And during an online presentation Nov. 17, the professor of health law, policy and management said every social determinant of health has its origins in a policy decision. Researchers who dig deep enough will find the roots in acts of Congress, state regulations, local ordinances and many other types of policies. (Here’s a link to an interview of Dawes)

Dawes is the most recent health equity thought leader to be featured in an ongoing racial health equity project of Spectrum Health Lakeland called Community Grand Rounds: Healing the Trauma of Racism. Although his assessment was unsparing of how racialized health inequities have gotten such a grip on the U.S.—“Racism doesn’t sleep in America, and hate never takes a break”—he offered much reason for optimism. 

His hope rests largely in the very force that created the health disparities in the first place. “Policy can be used as a driving force to advance health equity in America, because, the truth be told, only policy can fix what policy has created in the first place,” Dawes said.

“Policy can be used as a driving force to advance health equity in America, because, the truth be told, only policy can fix what policy has created in the first place,” Dawes said.

He used “Jessica’s Story” to illustrate how profound the deficiencies for optimal health can be in some communities. Jessica, as seen in an animated video, is an amalgam of people who live in communities that Dawes said are “starved” for resources because of policy decisions over time. At 19 she gives birth to a premature infant whose umbilical cord contains more than 200 toxins, a consequence partly due to a dump and a chemical plant zoned for her community. 

Among the multitude of dismal factors Professor Dawes detailed in Jessica’s community are housing segregation and substandard apartments (partly owing to government-sanctioned “redlining”), a lack of sidewalks and parks, an absence of tenant rights leading to landlord abuses, the closing of a nearby community health center, low Medicaid reimbursement rates causing health care providers to stay away, a non-livable minimum wage—and many more factors that lead to poor health. 

Dawes said of this fictional Jessica with real-world problems: “She never knew the extent of how the appalling conditions of her neighborhood were politically determined. Jessica’s story shows the compounding effect of political determinants over personal responsibility. No matter how reliably Jessica tried to act, structural, institutional, interpersonal and intrapersonal obstacles stood in her way.

“High obesity rates, diabetes, maternal and infant mortality, depression and many other health issues can firmly be linked back to political action or inaction.”

“High obesity rates, diabetes, maternal and infant mortality, depression and many other health issues can firmly be linked back to political action or inaction,” he said. American slavery and its post-Civil War embodiment, Jim Crow, have had health repercussions that continue. Dawes said there is a direct link between Jim Crow-era conditions and the prevalence of aggressive breast cancer among Black women today.

Dawes said in 1641 a law was passed with profoundly bad effects through the centuries on the health of Black people. In that year, business interests, fearing the abolitionist movement, worked with policymakers in Massachusetts to create the now-strange-sounding Body of Liberties law to legalize slavery. Other colonies followed this template, and such laws and policies were recycled for years to come around the nation.

But throughout the nation’s history there also have been champions for health equity. Dawes cited the failure of an effort in 1789, the year the nation was formally established, to improve conditions, including medical care, for enslaved people and other marginalized people. Congress rejected the idea, saying the matter was up to the states. And in 1865, as the Civil War was ending, what Dawes termed “America’s first major health reform law,” the Freedmen’s Bureau Act, was created. Sanitariums, hospitals and clinics were established for newly freed Blacks, poor whites and others, but continual sabotage of the act led its dismantling within seven years.

It wasn’t until a century and a half later, when the Affordable Care Act, or “Obamacare,” was passed, that ”we were able to succeed in getting 62 provisions in that law to elevate the status of all communities: white, Black, Asian, Native American, you name it, making sure no one would be excluded,” Dawes said.

In each community, he said, the political determinants of health are created by three simultaneous processes that reinforce one another and open up—or prevent—opportunity for optimal health. One process is structuring relationships. Examples are policies that prevented interracial marriages and ones preventing children with disabilities from receiving formal education. The second process is distributing resources, including, among other things, federal, state and local discretionary funding. The third process is administering power. Efforts to restrict voting are among the powers he mentioned.

Dawes said “the great news” in the continuing push for health equity in the U.S. is that structural barriers and the resulting inequities are not permanent. With deep knowledge of the political drivers of health inequities and perseverance for the long fight ahead, reformers can create new policies that improve living conditions—the social determinants of health. 

What won’t work are mere moral arguments about how some groups of people, such as people with mental illnesses and substance abuses, are dying prematurely. You can talk about suffering “until your tongue bleeds, but that won’t help your policy agenda to get over the finish line,” he said.

What seems to work best is tying health advocacy with the promise of saving money for the government and commerce. The creators of Obamacare consulted hundreds of admirals and generals in 2009 and found that 75 percent of young Americans were unfit for the military. He indicated that the threat of future economic and security problems from such an unprepared population helped the passage of Obamacare to ensure early interventions for healthier lives.  

“My argument to folks is a cost-savings argument.”

“My argument to folks is a cost-savings argument,” Dawes said, “because eventually it is very costly to exclude people. It is very costly in terms of health, productivity and lives, money, you name it, to prevent people from being able to reach their full potential.”