Democracy and Health II

This post is going to be another heavy slog through statistics. But I hope you’ll agree it is in pursuit of something important—imagining a healthy American democracy. So, I’ll start us off with a story that highlights the threat to it. In 1968 when I was only 12, I met one of my uncles from Yazoo City, Mississippi. Many in my family had ties to the White Citizens Council and other enforcers of racial segregation and I suspect he might have been one, but I didn’t know that then. I stopped at his house to introduce myself and we talked on the porch. He didn’t invite me in, which then was unusual in the South. He knew, of course, that I was a Yankee and the son of a civil rights supporter so even though I was only a kid, I could tell my presence made him nervous. So much so that he quickly began—strangely since this was a family visit—to explain to me his stance on the Voting Rights Act, which had only just been passed. He began by professing his love for the Black people of Yazoo County, but then descended to protesting that they must never be allowed to vote. He was soon yelling and shaking his fist, “I’ll be a dead man before a Black man votes in Yazoo County!” he shouted. Of course he did not die, and soon a Black man would become the mayor of Yazoo City. But the point is, preventing other people from voting has long been a way of life in this country. Now back to the science…

My last post, more than a year ago, was about the Health and Democracy Index, now produced by the Institute for Responsive Government. The Index (I’ll call it that for short) has a simple purpose, which is to demonstrate that when democracy is stronger people are healthier. It does this very well. States in which more people can vote tend to have residents who are much healthier than states where it is harder to vote. In the post I argued that this is at least in part because when people can express their preference for health through the ballot, politicians are forced to listen. 

I serve on the Board of Health of the Ingham County Health Department in Michigan. That means I am privileged to work with their talented staff, and we noted that the Index used data only at the national level. Since we work in local public health, we wondered together whether what the Index shows also holds true at the state and local level as well? In other words, within a single state or county, do areas where more people are civically engaged—voting for example—have healthier people than areas where folks are less engaged? 

We found that the answer is yes for the local level; neighborhoods differ in the same way as states. However, there are a lot of interesting details, so I encourage you to read on. 

I’m not going to describe the original Health and Democracy Index completely in this post. You can read all about it here, and anyway, I want to use this post to fully describe what we did to create the local version. But let me begin by showing you the main chart from the original national index. 

The cloud of data points represents the fifty states. The horizontal axis is an index composed of measures of state electoral laws and policies. Toward the left are states with laws and policies that tend to restrict access to voting and toward the right are states with easier access. The vertical axis is an index composed of common measures of health, with healthier states being toward the top. So you can see that states with more access to the ballot on the right side of the chart tend to cluster at the top, meaning the stronger a state’s democracy the healthier its residents are. For the stats nerds (who always complain if I don’t do it) I have included a regression line and the relevant statistics for this chart. If you just want to contemplate one number, look at the one called R2 (r-squared). It is .46 which means the relationship between voting and health at the national level is very strong. 

Before I go on, I want to clarify what I am claiming here. We are not arguing that access to the ballot by itself is responsible for all differences in health between states. What we are looking at are consistent and powerful historical differences between regions of the country. Different groups of people occupied different parts of the country and subsequent social and economic development transformed regions of the country differently. 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. In other words, historical conflict created both the voting laws and health policies of the states. Once in place, the voting laws probably tended to reinforce health inequities. After we look at the data on the relationship between voting and health at the state and local level we will discuss how this may manifest itself even at the most local level. 

We decided to try to replicate the chart from the original Index twice: once at the state level and once at the county level, giving us three similar charts to compare. However, we had to do it differently in each case because of the difficulty of obtaining appropriate data at each level. The table below summarizes the differences between the measurement and results of the three charts and these will be discussed more below.  

Attributes of the Three Charts	National	State	Local
Measurement of Health	Index of Health Data	Stroke Mortality	Life Expectancy
Measurement of Civic Engagement	Index of Electoral Policies	Percent Voting	Percent Voting
Units of Analysis	States	Counties	Census Tracts and Precincts
Strength of Relationship	Strong	None	Moderate

Here is the chart replicating the Index at the state level. In this case the state is Michigan. The dots represent Michigan’s 83 counties. 

The horizontal axis is the percent of eligible voters in each county who voted in the 2024 general election. Some counties had very high voter turnout, around 90 percent, while others had very low turnout, around 60 percent. The vertical axis is a measure of health, the stroke mortality rate per 100,000 people. Stroke mortality is a robust indicator of population health that was included in the original health index. The counties with the highest stroke mortality rate (near 50 per 100,000) had rates almost 5 times higher than those with the lowest (near 10). 

There is one important difference between the display of the national and state level data. The index of health in the national data is positive—that is when it is higher it is good. But stroke mortality is negative. When it is higher that is bad. So we flipped the direction of the vertical axis in the state data so the two charts would look the same and be easily comparable. 

What you can see is that the relationship between civic engagement and health that we saw in the national data is almost gone in the state data. The data do not cluster and the regression line is almost flat. If you want a number to confirm what your eyes tell you, the R2 is only .05, almost zero. 

The reason the relationship between civic engagement and health has disappeared is because many of the low-income counties in Michigan that have high stroke mortality rates also have high voter turnout. For example, Montmorency county had the highest stroke mortality rate at 48.7 per 100,000, but it also had sky high voter turnout at 79.7 percent (Montmorency is the dot in the lower right hand corner). Rural Michigan counties are not like Appalachia or the deep South. They may have health problems, but they can also have high levels of political participation. This is at least partly because what counties must do under Michigan electoral law is set by the state, so it is no wonder that what we saw occurring between states has disappeared when we look within one. Of course, we only looked at one state; there may be other states, depending on their history and laws, where voting is related to health. But here we have showed, at least, that it isn’t necessarily so. 

Surprisingly then, the relationship between civic engagement and health reemerges when we look at the most local level, within one county, in this case Ingham County, Michigan. Before we look at the chart let’s look at two maps to get an idea of what our County level health and voting data are like. The map below shows life expectancy by Census tract in Ingham County. 

The data in the map are grouped into equal sized quartiles and color coded to make it easy to see where life expectancy is longest and shortest. Darker colors indicate longer life expectancy. The white spaces had too few deaths to calculate life expectancy. The tract with the longest life expectancy is an affluent suburb of East Lansing with an average life span of 86.6 years. The tract with the lowest life expectancy at only 69.7 years is an urban neighborhood located in central Lansing. 

The next map shows voter turnout in the 2024 general election by electoral precinct, also color coded in equal sized quartiles. Voter turnout varied widely with the highest turnout being in Meridian Township, an affluent suburb where 86.4 percent of those eligible voted. The lowest turnout was in Central Lansing at only 42.9 percent. 
 

When you consider the two maps together, they appear to be similar in some ways. The longest life expectancy and highest voter turnout (dark colors) are both found in the northeastern part of the county where home values and incomes are high. The lowest life expectancy and lowest voter turnout are in the urban core. There isn’t a clear pattern in the southern part of the county. So, when we chart the data what will we get? 
 

There is a moderately strong relationship between civic engagement and health at the local level. Neighborhoods with the highest voter turnout tend to be the ones with the longest life expectancy and they are clustered in the upper right-hand corner. Neighborhoods with low turnout and shorter life spans tend to be in the lower left. The regression line is steep again and R2 is .30, not as strong as at the national level, but still large for social science data. 

Before I go on you may notice that some of the dots in the chart seem to be arranging themselves in straight lines. What’s going on? In the earlier charts we had only one unit of analysis: just states at the national level and just counties at the state level. But at the local level we have two units of analysis: Census Tracts for life expectancy and electoral precincts for voter turnout. They don’t line up perfectly. So the chart of local data is asking a slightly different question than the charts of national and state data. At the national level, for example, we are asking if our units of analysis, states, have both better health and easier access to the ballot, or vice versa. At the local level we are asking if one of our units of analysis, Census Tracts, have long life expectancies and are overlapping other units of analysis, electoral precincts, with high voter turnout, or vice versa. This approach is called overlay analysis. 

You can see this clearly by looking at the line of dots at the top of the chart. That is our previously mentioned affluent East Lansing neighborhood with a life expectancy of 86.6 years. It overlaps ten different electoral precincts. Most of the precincts it overlaps had high turnout with the highest being 81.6 percent. But a few had low turnout, including one as low as 58.4 percent where East Lansing meets Lansing. Taking all such pairs of overlapping Census Tracts and precincts, we ended up with 380 data points in the chart. The statistics on this chart tell us that in spite of some exceptions, high life expectancy Census Tracts tend to be overlapping high turnout precincts and vice versa. 

So what does it mean that we find the relationship between health and civic participation at the local level that we first saw at the national level? It makes sense that we should see that relationship at the national level because states developed different electoral and health policies for important historical reasons and they apply them throughout their jurisdictions. But at the local level Census Tracts and precincts are all subject to the same state and local laws and policies. Shouldn’t they all be the same? 

I think two things are going on. One is we know that lower income people tend to be less healthy. Furthermore, people are profoundly sorted along economic lines at the neighborhood level. As we say in local public health, “Your zip code determines your life span”. Lower income, less healthy people are concentrated in places with affordable, often poor quality, housing. This is the result of policy failures that entrench inequality. Furthermore, these people may have an ambivalent relationship with government including voting. While most low-income people do vote, many still might not feel safe or welcome at the polls and even if they want to vote they might not be able to get there. So lower turnout by low-income people means policies that entrench health inequities persist—civic participation or its absence is driving health even at the local level. 

Another possibility is that even though all local electoral precincts are subject to the same policies and laws, there may not in fact be equal access to the ballot. It could be that even though the County Clerk may intend for people in downtown Lansing to have the same access to the ballot as people in the suburbs, things may not have worked out that way. This is something we intend to test in the next half of this project by looking at the locations of polling places, drop boxes, staffing levels, accessibility and hours of operations. We will share our findings with community organizations with whom the Health Department collaborates to see if there is some basis for action to meaningfully increase access. 

There have been many partners in this project. The Ingham County Health Department has taken the lead, and will present its findings at Michigan’s Premier Public Health Conference in October. The Michigan Public Health Institute has advised on the project and is interested in determining whether it can encourage other local health departments to adopt this approach. The Institute for Responsive Government has offered a great deal of technical assistance. And Barb Byrum, the Ingham County Clerk has helped us understand the availability and use of electoral data. If things go as planned this Fall, we will have plenty of input from community organizations on whether and how to help increase access to the polls in Ingham County and Lansing neighborhoods.  

Sources: 

• Michigan 2024 Census Tracts and Voting Precincts, Center for Shared Solutions, Department of Technology, Management, and Budget, State of Michigan. https://gis-michigan.opendata.arcgis.com/. 
• Michigan 2023 Stroke Mortality Rates by County. Michigan Department of Health and Human Services. https://vitalstats.michigan.gov/osr/deaths/StrokeCrudeRatesTrends.asp.
• US Life Expectancy at Birth 2023. National Association of Public Health Statistical Information Systems. https://www.naphsis.org/usaleep.
• Ingham County 2024 General Election Turnout by Precinct. Ingham County Clerk. https://clerk.ingham.org/departments_and_officials/county_clerk/election_results.php. 
• Michigan 2024 General Election Turnout by County. Michigan Department of State. https://www.michigan.gov/sos/elections/election-results-and-data. 

Democracy and Health

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: 

 Sure enough states with the poorest access to the ballot were most likely to restrict public health (If you are into stats, chi-square for any restriction on public health is 20.69 (p<.00001)). Among the states with the highest cost of voting almost all (15 of 17) limited public health in some way. Only two of the states with the lowest cost of voting did so. On average high cost of voting states placed more than two legislative restrictions on public health. Six high-cost states placed restrictions that the Policy Surveillance Program labelled as extreme, while none of the low-cost states did that. So here is a clear example of places with different levels of democracy getting different policies with respect to health.

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.

How Public Health Can Respond to Dysfunctional Politics

Lori Tremmel Freeman is the executive director of the National Association of City and County Health Officials (NAACHO), the professional association that represents local health departments. She wrote an excellent article in the American Journal of Public Health accurately describing the attacks on public health during the COVID pandemic and calling for legal protections for local public health workers. Director Freeman said…

“Many of these attacks on public health are surprisingly well organized. Groups such as Freedom Angels, Sovereign Nation, the Boogaloo Boys, and Colorado Counties for Freedom have coordinated strong pushback on public health measures in communities and have specifically targeted local health officials by generating messaging that includes personal attacks on integrity, conducting in-person demonstrations at the homes of public health officials, taking out radio advertisements against public health, and using other tactics to pressure public health officials regarding unpopular health orders and mitigation efforts.”

These attacks cost lives. Using my home state of Michigan as an example, I estimate that at least half—maybe as many as 20,000—of Michigan’s nearly 40,000 COVID deaths resulted from these attacks (I explain how I arrived at that figure at the end of this post).

In other articles on this blog, we explain why this happened. Early in the pandemic political leaders clustered around former President Trump realized that memes attacking public health were effective in mobilizing their extremist political base. Adopting positions to galvanize the base, regardless of the consequences, was part of the overall effort to subvert the 2020 election and many anti-public health activists were also involved in the assault on the capitol on January 6^th. Unfortunately, local political leaders seeking to advance their own careers eagerly supported this effort and were actually the ones who did the most to spread COVID by encouraging people to forgo masks, spreading anti-vaccination fever and overturning public health orders. (Many of these details are in the previous post.)

Ms. Freeman’s article, with its acknowledgement that she knows what we went through and its description of NACCHO’s concrete efforts to help, is welcome. Here, however, I want to push a little farther. Her article, I’m sure she would agree, calls on legal authorities to do their duty to support public health, but it does not propose long-term solutions to the problem of widespread anti-public health mobilization. But we cannot protect the health of our communities if half the public is up in arms against us, even if we have good police protection. As public health well understands, health flows from the sense of being part of a caring community and a desire to sacrifice for the welfare of that community, not from the threat of a visit from the cops. This is what we lose when elected leaders, who are in fact themselves responsible for protecting the health of the public, instead try to score points with the base by repeating popular lies about public health. Therefore, we must develop the capacity to grapple with and overcome this political dysfunction. The purpose of this post is to talk about what public health must do right now to address this political dysfunction.

I’ve been doing a lot of public speaking about this topic. I have noticed that when people in public health try to talk about how to rebuild their profession, they tend to get stuck in two places which have to do, first of all, with the problem of how we communicate, and secondly with the problem of our failing of our democracy.

The first place where public health gets stuck is the problem of communication. People keep trying to think of better and better ways to explain to others that COVID (or some other health threat like climate change) is real and that they need to take precautions against it. I think people get stuck here because they are, in fact, already really good at explaining this. There isn’t a better way. I do not mean that good public information practices such as those advocated by Peter Sandman are not important, they are, and we should always strive to fix mistakes and improve. What I do mean is that research on public health communication shows that the current structure of the internet blocks public health communication. There has been an explosion of such studies and they show that disinformation spreads faster and farther than accurate information on social media. This includes your favorites like Facebook, Twitter and TikTok. As Jones, Trice, Olaniran and Williams concluded in the Nature Public Health Emergency Collection (doi: 10.1007/978-3-030-36525-7_5) online communication has become “pathological” and “it is imperative to figure out a way to maintain sensible dialogues that promote democratic principles”. This means that even though public health is communicating like crazy, many people never hear us anyway, so our efforts don’t influence enough people to prevent a lot of deaths. (The bibliography found on this website lists some of this research.)

If I can get my audience to understand that fixing public health is not about them saying things in a better way, they get stuck again, because they can’t think of what else to do. This is the problem of our failing democracy. Today public servants in health, education and many other fields can’t ask elected leaders to do their jobs and can’t call on other agencies for support—the system is locked in partisan conflict, and nothing seems to be working the way it is supposed to.

Fortunately, my co-authors on our upcoming article in Health Promotion Practice have developed a really clear proposal for the public health community about exactly what our next steps should be. What they came up with is summarized in this draft, but here I’ll try to provide a brief synopsis: There have been a number of changes in how politics works in America that mean that people running for office are not rewarded for getting good public policy outcomes, but they are rewarded for stirring up an extremist base. Some of these changes include the rise of social media, which we already discussed. To this we need to add copious dark political money and also anti-democratic practices like gerrymandering and voter suppression. We can’t fix public health until we undo these changes first.

Let’s start by looking at how to make the Internet work better. Hundreds of millions of people use social media platforms without understanding basic facts about health or about their democracy even though they spend hours a day engaged with these topics. One thing that would not help would be censorship or policing the content of what people say online. What we ought to do is make Internet use improve people’s knowledge. To do this we could require social media platforms to be licensed, and as a requirement of licensure they would have to demonstrate that their users have a minimum level of media, health and civics literacy. This is the same way we regulate hospitals. We require health care providers to show that most of their patients get better; if they don’t get better, we can yank their license and give it to another provider whose patients do get better. If we treat social media the same way, it would go a long way toward blocking disinformation.

While we are dealing with disinformation, we also need to address anti-democratic practices including dark money, gerrymandering and voter suppression. The dominant model of public health, promoted by the Public Health Accreditation Board (PHAB) assumes that public health is part of a real democracy. It assumes elected leaders have appointed public health officials because they (the elected leaders) feel responsible for protecting the health of the public, and that elected leaders therefore are listening to the advice they are getting from their appointees even if they sometimes disagree. When this is true it represents a very healthy form of democracy. But it is not true. In many places in our country political jurisdictions are so captivated by disinformation, so awash in dark money, so gerrymandered and voter suppression is so effective that political races are not competitive, and politicians gain power by activating their extremist not by fixing real world problems. And they do this by making up scary stories about non-existent government plots.

One reason public health may have let extremist politics get the upper hand, is that public health workers sometimes say they cannot take a stand on political questions because of Hatch Act type state laws. What most of these laws mean is that government employees are not supposed to seek favors from elected officials to line their own pockets, which is a good thing, but the laws actually don’t block most kinds of political activity. In fact, public health can take a stance in favor of real democracy. Public health is already explicitly anti-racist and anti-sexist. We already advocate for social justice and health equity. All of these things depend on a healthy democracy.

Before we close, I want to talk about one other thing—holding leaders accountable. To fix communication and elections we somehow need to get new laws through legislatures whose members benefit from the status quo, so they are likely to resist us. It might be necessary to turn up the heat to get them moving. How do we do that? It might be necessary to apply some pressure in the form of holding them accountable. One way to do this is by using gross negligence laws or class action lawsuits. By any reasonable standards our leaders have been negligent and have harmed entire classes of people. Consider the following:

In 2017 after the Flint water crisis the former director of the state health department in Michigan, Nick Lyon was charged with manslaughter. Twelve people had died of legionella in one summer because the water was not properly treated. Director Lyon was not charged because he knew the water was dangerous but allowed the plan to go forward anyway. He thought it was safe. He was charged because he was insufficiently curious about why people kept protesting despite the reassurances he had received. Contrast that with the COVID pandemic. During the pandemic leaders were told over and over again by their own scientists not to do what they were doing. They were told many times that their actions were spreading the disease and raising the death toll. Yet they persisted. The result was that multiple dozens of people in Michigan died every day, and the dying went on in waves over two years.

I am not in favor of punishing anyone for what happened. I believe in truth and reconciliation. I want to fix what is wrong and move on.

But remember, Lyon was charged by the same conservative Republicans who later spread COVID to their constituents. If we have to turn up the heat to get action, we should do it. 

====================

Note on Methods: The four big Michigan counties with very strong COVID policies had total COVID mortality of 2,219 per million people. The 22 counties where essentially there was little effort to fight the pandemic had total mortality of 4,101 per million which is almost exactly twice as high. This disparity is the same pattern seen nationally.