Deliberative Dialogue and Decision-Making about U.S. Population Health Challenges: A Pipe Dream or a Possibility?Erika Blacksher
To describe the United States as deeply divided no longer captures the scope or urgency of our predicament. Increasing numbers of Americans now endorse political violence as a legitimate means to achieve one’s goals. Some believe a civil war is next.
Violence has been directed not only at the nation’s political institutions and public servants in response to the contentious elections of 2016 and 2020, but also toward public health and healthcare professionals who have served on the frontlines of the COVID-19 pandemic. In this context, it may seem brazen or naïve to suggest that people diverse by race, place, class, and political orientation can come together to learn, talk, and decide together about how to address some of the nation’s most pressing population health challenges. But that is precisely what a new project aims to do.
With funding from County Health Rankings & Roadmaps (CHR&R), a program of the Robert Wood Johnson Foundation, Dr. Erika Blacksher is leading a research team, supported by expert advisors, to create a democratic deliberation toolkit. In its proof-of-concept phase, the project aims to learn whether good deliberative conditions can disrupt everyday reasoning habits, short-circuit stereotypes, and cultivate population health dialogues that are more curious, inclusive, and characterized by mutual concern and trust.
What is democratic deliberation?
Democratic deliberation convenes people with diverse perspectives in reasoned dialogue about value-laden questions in search of collective solutions., Empiric evaluations have shown it can yield informed, considered, and public-spirited discussions.,,,, A controlled trial has shown that it increases knowledge among participants, regardless of education level, race, or ethnicity, and is especially valued by racial minorities and people with lower levels of educational attainment., Democratic deliberation has been used around the globe to gather public input on contentious issues, even in deeply divided societies that have experienced sectarian violence and civil war,. Although deliberation has gained traction in the U.S. health sector and bioethics, few have focused on the poor state of the nation’s health and health inequalities.,,,
How do we talk about population health and health inequalities?
One of the project’s most fundamental challenges is how to talk about the nation’s population health challenges. A basic tenet of democratic deliberation is non-partisan framing. The information (e.g., briefing materials, expert presentations, case studies) needs to be inclusive and balanced; the questions need to not lead deliberants one way or the other. Ample science points to many communication challenges.,,,20,21,22 Some people may reject as erroneous or biased the very premises (e.g., health equity), frameworks (e.g., structural racism), and findings of population health science. Left-leaning and right-leaning people tend to prefer different phrases and metaphors to describe health issues, e.g., Democrats are amenable to “systems”; Republicans to “journeys.” Some words may activate partisan reactions, including ideas integral to population health such as “social determinants.” Fortunately, the research also points to potential strategies for effectively conveying information about population health across our many divides.
What are the next steps?
Such challenges, and the project’s goals, have guided every aspect of the design. For example, the deliberation will allow plenty of time for formal and informal conversation and connection, and overnight reflection—2 days, 14 hours total. Longer deliberations have been shown to be more effective in respects central to the project’s goals. The facilitation team will be multiracial. Case studies will feature a range of population health challenges that have differential impacts by race, socioeconomic status, and gender, and framed within the nation’s overall poor health . Recruitment will oversample groups that experience excess poor health and early death. These are just a few of the many decisions that need to be made in designing a deliberative study.
Whether or not good deliberative conditions can enable people from all walks of life to learn and talk together with mutual respect and shared purpose remains to be seen. The deliberations will not be piloted until 2023, once we secure funding. But that we need to find a way to talk about the nation’s significant health inequalities, declining life expectancy, and overall poor health is an ethical, policy, and political imperative.
 Rachel Kleinfeld. The Rise in Political Violence in the United States and Damage to Our Democracy. Testimony before the Select Committee to Investigate the January 6th Attack on the United States Capitol. March 31, 2022. https://carnegieendowment.org/2022/03/31/rise-in-political-violence-in-united-states-and-damage-to-our-democracy-pub-87584
 Rodrigo Pérez Ortega. Half of Americans anticipate a U.S. civil war soon, survey finds. ScienceInsider. July 19, 2022. Available at: https://www.science.org/content/article/half-of-americans-anticipate-a-us-civil-war-soon-survey-finds
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