The Political Determinants of Health: Our Next Book Review

Have you ever thought of health equity as a movement? After reading this book, you will.

I often think of health equity as a process and an outcome that relates to practical policy implications. Among the political hostility that plagues today’s society, policy implications that advance health equity can seem aspirational–or worse, unattainable. The Political Determinants of Health, by Daniel E. Dawes, JD (Johns Hopkins University Press, 2020), is a must read for the moment we find ourselves in. This book illuminates the health equity movement that began before our nation’s founding and persists today. Dawes helps us remember how we got here. He recounts the struggles, wins, and aftermath of past and contemporary health equity advocacy and policy actions in the United States. Notably, this book details a paradigm-shifting framework called the political determinants of health model. The goal is to clarify and encourage thinking about how the political determinants of health can be leveraged to derail structural racism, in the form of policy, to advance health equity. Below, I highlight the seven parts of this book.

The Allegory of the Orchard

Dawes opens this book with a cautionary tale about a farmer who looked to increase his wealth by establishing an orchard. This farmer acquired land that contained plots with different soil qualities. During planting, the farmer provided different levels of care and fertilizer to seeds according to the plot’s quality. These differential investments advantaged seeds planted in the high-quality plot, and disadvantaged seeds planted in the lower-quality plots. As the seeds mature into trees, it is evident the farmer’s orchard is less than what he could have had. Dawes explains the farmer represents the government, the seeds represent the people, and the soil represents housing – a social determinant of health. He takes care to highlight the farmer’s responsibility in making the soil suitable for all seeds to mature and thrive. Inequity is at the root of this status quo. This introduction profoundly calls out the ways that health, and thus justice, is advanced or hindered through the action and inaction of actors.

Setting the Precedent

In Part 2, the author lays out how long the United States has grappled with advancing health equity through the political process. He moves the reader through the history of the health equity movement and discusses four significant attempts advocates made to achieve health equity through policy, spanning nearly 250 years. This section reminds us that “policy reflects the values of its time” and thus cannot be meaningfully changed without understanding the problem within its temporal context and the policy standards that exist at that time.

The Political Determinants of Health Model

In Part 3, Dawes defines the political determinants of health and presents his framework. According to Dawes, there are three major political determinants of health – voting, government, and policy – that shape opportunities in ways that either advance health equity or exacerbate health inequities. He compels the reader to see the profound role political determinants play in structuring social, environmental, and other determinants of health inequities. He also names four arguments (moral, outcome, economic, and national security) that have proven successful over time to overcome structural, institutional, and interpersonal barriers that prevent us from prioritizing health equity in policy.

How the Game is Played

Part 4 provides interesting details on how the alignment of two political determinants —voting and government — led to the development of the Affordable Care Act (ACA). The author acknowledges the instrumental roles played by stakeholders, community leaders, health equity proponents in Congress, and staffers that led to the drafting of a health reform bill that would become the ACA.

Winning the Game that Never Ends

Part 5 documents how the Obama administration traversed the political minefield to pass the most inclusive health equity policy in the history of the United States — the ACA. It spells out how advocacy was and is still essential to protect this groundbreaking piece of legislation and other laws and policies that advance health equity.

Growing Pains

Part 6 highlights the power and challenges of advocacy during the Trump Administration’s efforts to undermine the ACA. The significant changes in policy and government that occurred after the Obama Administration’s timeframe show how health equity proponents and opponents used advocacy to influence the political determinants of health inequities, especially during a challenging. After all, the political determinants of health are not permanent.

The Future of Health Equity Begins and Ends with the Political Determinants of Health

This final part opens with a quote from James Baldwin: “The price one pays for pursuing any profession, or calling, is an intimate knowledge of its ugly side.” This truth encapsulates the tone of Dawes’ exposition of the political determinants of health at play in two life sources. The first source takes the reader to the water crisis in Flint, Michigan, where deeply embedded institutional and historical racism resulted in (local) government-sanctioned lead poisoning in drinking water that has damaged generations of Genesee County residents. We see how residents leveraged the political determinants of health to uncover and rectify some of the issues with their source of drinking water. The second source explains the systemic nature of nutrition inequities in the United States. Through policy and lobbying, readers see how the United States’ stance on food and nutrition has shifted from rejecting its responsibility to treat undernutrition, to providing poverty-related nutrition aid, and to now supporting the mass production of poor-quality, cheap foods that shaped our obesity epidemic.

Final Thoughts

With the 2024 US presidential election looming in the not-so-distant future, The Political Determinants of Health is a must read. This latest offering by Daniel E. Dawes leads us into a conversation that is both thought-provoking and action oriented. This book gives us a way to think critically and strategize about how to use the political determinants at our disposal to make a collective impact to advance health equity. It shows that the health equity movement is a fight for justice. And if there is any doubt, in the foreword, Harvard Professor David R. Williams reminds us “…the fight is far from over.”

About the Book’s Author

Daniel E. Dawes, JD is a widely respected and internationally recognized attorney, scholar, and health policy expert. He is co-founder of the Health Equity Leadership and Exchange Network (HELEN), elected member of the National Academy of Medicine, and author of 150 Years of ObamaCare (released in 2016). Dawes currently serves as Senior Vice President of Global Health Equity and Executive Director of the Institute of Global Health Equity at Meharry Medical College in Nashville, Tennessee.