A recent analysis of all-cause mortality rates found that there were 74,402 excess deaths among Black people compared with white people each year between 2016 and 2018 in the 30 largest U.S. cities. That tragic inequity is no accident, according to one acclaimed expert on health equity.
“It's not a coincidence that certain groups of people in America experience higher premature death rates or poorer health outcomes than others,” said Daniel E. Dawes, Professor of Health Policy and Executive Director of the Satcher Health Leadership Institute at Morehouse School of Medicine.
“The nation's health isn’t an organic outcome,” Dawes said, noting that government policy has been used to embed racism and discrimination into “the structural foundation of this country.”
Dawes, author of the 2020 book The Political Determinants of Health, made those remarks while speaking at “Righting the Wrongs: Tackling Health Inequities,” a virtual summit hosted by the Hastings Center and co-sponsored by the AMA.
What matters for health
Dawes noted there is a growing recognition that social determinants of health, such as people’s level of food and housing insecurity, often have more impact on well-being than any health care services they may receive.
But he added that the political determinants of health that form “upstream” from social determinants provide the momentum to create and sustain health inequity.
“The political determinants of health involve the systematic process of structuring relationships, distributing resources, and administering power,” Dawes explained. “These political determinants of health inequitably distribute social, medical and other determinants, and create structural barriers to equity for population groups who lack power and privilege.”
Learn about the AMA Center for Health Equity and the AMA’s strategic plan to embed racial justice and advance health equity. The Satcher Health Leadership Institute at the Morehouse School of Medicine and the AMA have collaborated to offer the Medical Justice in Advocacy Fellowship.
Origins of political determinants
The nation’s political determinants of health started to take shape early. In 1670, the New England colonies’ Body of Liberties legal code was amended to mandate that the offspring of enslaved women would be born enslaved.
“From a political determinants of health lens, it is here when the roots of inequity began to enroot and incubate in America,” Dawes said. “When the commercial interests—wanting to sustain their business model of slavery—worked with policy makers to codify this evil institution into law.”
After the U.S. won its independence, abolitionists petitioned to “secure the blessings of liberty” to all, Dawes said, but were rebuffed by Congress. The majority of those congressmen enslaved people, he noted.
In the 20th century, the U.S. government continued to create racist policies, though in form they were often “facially neutral,” Dawes said.
These included the:
- Home Owners’ Loan Act of 1933, which led to redlining neighborhoods as high risk and led to the denial of loans and investments that could have created economic opportunities in low-income areas.
- Social Security Act of 1935, which intentionally excluded domestic workers and agricultural laborers who were mostly African Americans or immigrants at the time.
- Federal-Aid Highway Act of 1956, which leveled poor neighborhoods to build expressways while sparing middle-class and affluent white areas.
Today, Dawes argued, there is a “poverty tax” levied on low-income neighborhoods that leads to higher interest rates on mortgages, higher premiums on homeowners and auto insurance and, in some cases, even higher grocery prices.
The effects of these policies are clearly seen in higher rates of asthma, cancer, heart disease and lupus found in economically or socially marginalized areas “owing to the structural conditions these communities find themselves in,” Dawes said.
Watch a “Prioritizing Equity” video discussion about the long-term effects of political determinants on health equity.
