Our democracy’s vulnerability to demagogy damages our health. On this blog I’ve used the COVID pandemic—in which politicians attempting to mobilize their base encouraged people to do things that spread disease—as a case study of this phenomenon.
But do we have any evidence that the reverse is true? Can we show that people are healthier when democracy is strong? My colleagues at Healthy Democracy Healthy People (HDHP), a public health advocacy group with which I am volunteering, have published some cool research tools to show just this. These tools, called the Health and Democracy Index (“Index” for short), provide evidence that people are healthier when they can express their preferences for policies or politicians that promote health through the ballot. Because of this, in 2024 HDHP is launching the We Will Vote campaign in coordination with numerous other pro-democracy groups focusing on electoral participation by the health sector.
I’m going to do three things in this post: first, I’ll show you the Index which demonstrates that states with stronger democracies are healthier; then I’ll show you that during the COVID pandemic, politicians in states with weaker democracies really did promote policies that hurt health by placing restrictions on public health; and finally I’ll show you that people in places where public health was restricted were more likely to die during the pandemic.
It is often said that the apparent relationship between democracy and health is not real, that is, democracy does not cause people to be healthier, rather regional sociological differences are responsible for different attitudes toward both politics and health. In some places, people both support (or at least tolerate) restrictions on voting and also are skeptical of public health. And so I’ll conclude with a discussion of the genuine significance of these regional differences, while reminding us that the periodic expansion of democracy in this country has been accompanied by real improvements in health.
To see the Health and Democracy Index, go to democracyindex.hdhp.org and scroll
down half a page. You’ll see a chart with a cloud of data points representing
the 50 US states (no territories or DC). You can do lots of things with the charts
and data here, but I’ll only be talking about this chart for now. In case you
don’t have a browser handy I downloaded the data from the website and made this
for you:
The horizontal axis is “Voting Access” and the vertical axis is “Health”. The cloud of data points is strongly clustered and slopes up to the right, suggesting that the more voting access people have, the better their health. So, if you think that the science behind this chart is valid, here is evidence that we could improve health if we strengthen democracy.
So, is the science valid? I’m going to take some time now to break this down. Voting access—which is used here as an indicator of democracy—means the Cost of Voting Index developed by political scientists with support from Northern Illinois University. It measures how hard it is to vote by state and is comprised of things like automatic and same-day voter registration, vote-by-mail and onerous ID requirements. There are around 55 elements in the Cost of Voting Index and its developers used a technique called principal components analysis to create an index from them.
Health means an index of overall health by state created by America’s Health Rankings and published annually by United Health Foundation. It is comprised of factors like the mortality rate, suicides, drug overdoses and infant mortality—there are well over a hundred of these—which are then converted into a single index (by weighting z-scores if you’re into stats).
The chart that I made includes a regression line and tests for statistical significance and strength and I put these on the chart for you. I won’t try to give a primer on statistics here, but in short, the p-value (p<.00001) means there is almost no chance these data points are just a random cloud, and the R-squared (R2 = 0.46) means the relationship appears to be very strong. Instead let me try a commonsense way of explaining things by showing that differences in health between states with different levels of access to voting are big enough to be meaningful in real life. Let’s take three of the states with the best access to voting (Hawaii, Utah, Washington) and three with the worst (Georgia, Missouri, Mississippi) and compare them on one of the measures of health included in America’s Health Rankings—the age-adjusted cardiovascular disease (CVD) mortality rate in 2021. The three states with the best access to voting have a CVD mortality rate of 151 per 100,000 people compared to 206 for the states with the worst access. The CVD mortality rate is 37 percent higher in the three states with poor access to voting. Clearly democracy is associated with differences in health that are big enough to meaningfully affect people’s lives.
Here in Michigan, it does feel like more democracy has led to more health. After we got rid of our gerrymandered voting districts by ballot measure in 2018, we elected a legislature that passed a raft of pro-health bills and a reelected a Governor who signed them in 2022.
Do states with weaker democracies really have worse health policies? When I first saw the Index, it made me think about the anti-democratic behavior directed at public health I witnessed during the COVID pandemic. I wondered whether states that had a high cost of voting would also be states whose legislatures had attacked public health over COVID policies. I cast about for a way to honestly measure which states had placed legal restrictions on public health and discovered the Law Atlas Project at Temple University. I used the data in their Policy Surveillance Program database to count the number of restrictions state legislatures had placed on public health in 2021—the year this was happening a lot. The restrictions included things like preemption of vaccine or mask orders, limiting the ability to control behavior in businesses or schools and transferring public health power to the governor or legislature. I broke the states into three groups of almost identical size (17, 16, 17) in terms of the difficulty of voting (high, medium, low) and counted the number of states in each group that had placed any restriction on public health in 2021. I also counted the average number of restrictions enacted by states that year and whether they had imposed severe restrictions as defined by the Law Atlas Project. I made this chart to show what I found:
If you restrict public health during a pandemic, maybe you’ll get higher mortality as a result. So, were there actually health consequences associated with different policies toward public health? Below is a map showing the COVID mortality rates by state in 2021. States that placed restrictions on public health are outlined in red. You can see with your own eyes that the states that restricted public health were often the ones with the highest rates of COVID mortality.
Even though a few states don’t seem to fit the pattern, the weighted average COVID mortality rate was 89.3 in states that did not restrict public health but 118.3, in states that did (T=3.4, p<.0013). It was 123.4 in states that enacted “extreme” restrictions. Your chances of dying were a third higher in an anti-public health state.
I do not think the policies per se caused most of the excess COVID deaths. In some cases the pandemic was over before the policies could do that. But I do think that political behavior killed people. Remember politicians in places that turned against public health were summoning people to maskless political rallies where health officials were denounced, promoting anti-public health conspiracy theories, and encouraging people hold proms, sporting events and the like while deaths were peaking. This political behavior both intensified cries for restrictions on public health and simultaneously spread the disease. Many other analyses have already shown that the single most important non-clinical factor associated with COVID morality was not race, income, education, etc. but was party identification (JAMA Intern Med. 2023;183(9):916-923. doi:10.1001).
Because of my career in public health, I know that almost all measures of health—including those in America’s Health Rankings—are correlated with lots of other things besides voting: education, income, race and social class; but not only that, health is correlated with things like attitudes toward capital punishment, immigration, abortion, you name it. These consistent and powerful regional differences in the United States exist because different groups of people occupied different parts of the country and subsequent economic development transformed regions of the country differently. I want to avoid characterizing those differences here because I risk oversimplifying a complex history (I’m not going to call the south “conservative” and the north “liberal”—oops!). But in brief, Appalachia, the Mississippi Delta and the southern border wound up with political systems more concerned with maintaining social control than other areas—control of unruly rural Whites, African Americans, Hispanics and Native people—and less concerned with winning support by demonstrating the ability to improve people’s lives.
Sometimes public health still explains regional differences in health by saying that Colorado and Vermont are healthier because they jog more, or that Mississippians (where I was born) are less healthy because they eat too much pecan pie (don’t get me started). I am saying that behind those slight differences in behavior are profound historical differences that keep asserting themselves, that continue to shape public policy and sometimes cost people their lives today.
Moments ago I got off a podcast about We Will Vote. I heard two things that have stayed with me. Jeanne Ayers, Executive Director of HDHP, reminded us that the expansion of democracy has often coincided with improvements in health: votes for women and reductions in child and maternal morality; the voting rights act and reductions in racial health disparities. And Dr. Georges Benjamin, Executive Director of the American Public Health Association, summarized the event by saying “the most important thing” public health practitioners can do right now is political organizing. Not health education, not vaccination, not research. Organizing.