Navigating the Political Divide in Population Health

We are caring for a population amidst increased political polarization. Many people distrust known science, accepting opinion as fact. Furthermore, the medical community’s failure to distinguish accurately and consistently between what they know, what they think they know, and what is still unknown undermines their messaging, to the detriment of public health.

“Follow the Science”—a straightforward slogan used during the pandemic as a strategy to promote truth—can take on an ominous and conflicting meaning for some in our polarized political environment. While some truths are incontrovertible (“the earth is round” for example, although there are some who still believe otherwise), promoting truths about a novel coronavirus which remains a step ahead of science requires some humility. For example, when the Texas government lifted the mask mandate in April 2021, public health expert predictions of a COVID-19 surge never materialized.¹ Why the surge did not materialize is still conjecture.² When “follow the science” proves wrong, anti-science sentiment is emboldened. The science, in fact, is far more complicated than what can be accurately conveyed in news briefs or speeches.

Working within an academic discipline like population health can be insulating. Data that has been analyzed and gives what appears to be clear direction in how to improve the health of our population is readily accepted by academics, policy experts, and leaders charged with promoting the health of all populations of patients. I feel confident in what I teach but I realize that outside of my academic bubble (perhaps even in publishing this editorial) there are conflicting beliefs, fueled by countervailing evidence, and promoted by ratings-conscious news and social media. A recent editorial³ in JAMA outlines just how wide the political divide is when public opinion polls are considered in the future of health policy in the United States.

Being fortunate to wear both academic and clinical hats, I experience weekly reminders that what is accepted as clinical fact is not always accepted by my patients and their community, as illustrated by COVID-19 vaccine hesitancy and refusal.⁴ Ultimately, I have to acknowledge patient refusal of what I believe are lifesaving vaccines and am forced to reconcile facts based on the best scientific evidence available with patients who believe otherwise.

I recently watched a popular Netflix movie, Don’t Look Up. It is a drama and parody about how our political leaders and society confront the impending collision of a large oncoming comet with Earth. Under these circumstances, political leaders struggle with how to confront this urgent, uncomfortable truth. The driving concerns are the potential political ramifications of their decisions on the upcoming mid-term elections. Media in the movie, in turn, drive viewer ratings by stoking controversy, displaying public opinion polls about the percentages of people who believe the upcoming conflagration is real or not, and publicizing conspiracy theories countering the actual unavoidable reality.

What is clear from population health data is that the United States falls far behind other advanced nations in many health outcomes, including life expectancy, despite repeatedly committing far more resources to health care. What is also clear is the primary drivers for this failure are the persistent health care inequities rooted in longstanding political and social policies which have disadvantaged segments of our population since our country was founded. With the prolonged COVID-19 pandemic, the flaws in our health care system and social safety net have been further unmasked, highlighting how inequities in education, income, and housing can cripple a nation’s response to a crisis. Given these facts, improvements in US population health requires attention to disparities driven by social determinants of health. Daniel E Dawes recently published⁵ “The Political Determinants of Health,” a study of the historical political events that have and continue to support these social and health care disparities.

Correcting inequities can be threatening to those of us (including myself) who have benefitted from the longstanding status quo. As a child, I never asked, discussed, or was taught why some groups of people lived in places with more crime, and did not seem to do as well as we did. In fact, I acquired from my parents a sense of fear and distrust of those different from us. I am now ashamed that my implicit, ignorant assumption then was that others were somehow inferior. I did not begin to learn otherwise until I attended college and became part of a more diverse environment.

But even educating our children about the roots of inequities in our society, something I wish that I had experienced much earlier in my personal development and professional career, has become controversial. It has been captured and promoted by some media and politicians as “critical race theory,” a bogeyman that threatens our children’s education and our way of life. In fact, addressing systemic racism in classroom education has even been considered racist by some.^6-7

Inevitably, if we are to improve population health, a rallying cry must follow for harnessing the political process and implementing more equitable and inclusive health policies. First, several key questions need to be asked, and solutions need to be accepted across the political spectrum:

• What are the facts?
• Should they be addressed? If so, how?

Given the complexities of the political divide, how can those of us working in population health address health care disparities? For my part, I strive to:

1. Acknowledge the imperfection of science, while striving to improve the accuracy of what I teach;
2. Appreciate that the truth is usually far more complex than what many of us understand
3. Understand inequities, and understand that those who benefit from the status quo may be threatened by change
4. Grow in my understanding of the political determinants of health
5. Be humble, and recognize that caring students and colleagues may have very different opinions from my own, based upon alternative sources of data
6. Proactively reach across the political divide to seek common purpose
7. Always keep the ultimate goal in mind: a health care and educational system that promotes the greater health of all patient populations

References:

1. Svitek P. Texas coronavirus cases haven't surged since Gov. Greg Abbott lifted the mask order. Experts warn it's too soon to celebrate. The Texas Tribute. April 14, 2021. Accessed February 10, 2022. https://www.texastribune.org/2021/04/14/texas-coronavirus-mask-order-abbott/
2. Sullum J. The COVID-19 disaster that did not happen in Texas. Reason. April 21, 2021. Accessed February 10, 2022. https://reason.com/2021/04/21/the-covid-19-disaster-that-did-not-happen-in-texas/
3. Blendon RJ, Benson JM, Schneider EC. The future of health policy in a partisan united states- insights from public opinion polls. JAMA. 2021;325(13):1253-1254. doi:10.1001/jama.2021.1147.
4. Kaminski M. Population points: confronting vaccine hesitancy. Population Health Learning Network. 2021. https://www.hmpgloballearningnetwork.com/site/pophealth/content/confronting-vaccine-hesitancy
5. Erdelac L. Politics, power, and equity. Health Affairs. 2020;39(6). doi:10.1377/hlthaff.2020.00578
6. Ray R, Gibbons A. Why are states banning critical race theory? Brookings. 2021. Accessed February 10, 2022. https://www.brookings.edu/blog/fixgov/2021/07/02/why-are-states-banning-critical-race-theory/
7. Butcher J. Keep racist critical race theory out of K-12 classrooms. The Heritage Foundation. April 22, 2021. Accessed February 10, 2022. https://www.heritage.org/education/commentary/keep-racist-critical-race-theory-ideology-out-k-12-classrooms