The Political Determinants of Health

by Daniel E. Dawes, David R. Williams (Foreword)

Reduced life expectancy, worsening health outcomes, health inequity, and declining health care options--these are now realities for most Americans. However, in a country of more than 325 million people, addressing everyone's issues is challenging. How can we effect beneficial change for everyone so we all can thrive? What is the great equalizer?

In this book, Daniel E. Dawes argues that political determinants of health create the social drivers--including poor environmental conditions, inadequate transportation, unsafe neighborhoods, and lack of healthy food options--that affect all other dynamics of health. By understanding these determinants, their origins, and their impact on the equitable distribution of opportunities and resources, we will be better equipped to develop and implement actionable solutions to close the health gap.

Dawes draws on his firsthand experience helping to shape major federal policies, including the Affordable Care Act, to describe the history of efforts to address the political determinants that have resulted in health inequities. Taking us further upstream to the underlying source of the causes of inequities, Dawes examines the political decisions that lead to our social conditions, makes the social determinants of health more accessible, and provides a playbook for how we can address them effectively. A thought-provoking and evocative account that considers both the policies we think of as health policy and those that we don't, The Political Determinants of Health provides a novel, multidisciplinary framework for addressing the systemic barriers preventing the United States from becoming the healthiest nation in the world.

Genres: Nonfiction, Health Care, Politics, Medicine, Health, Social Justice, Audiobook

240 pages, Paperback

First published March 24, 2020

Reviews

[Lukas Lee · Rating 3 out of 5]

Political Determinants of Health are a critical topic that I feel should consistently be discussed alongside the more-mentioned Social Determinants of Health. I enjoyed the opening allegory and writing in chapters 1-3. Chapters 4-6 are a detailed play-by-play of the politics surrounding the ACA, specifically, that I felt was overkill. Wrapping up the book by outlining how political determinants of health factored into the Flint Water Crisis was a wise choice.

“As a society, we have been conditioned to believe that equality, which is giving everyone the same treatment, is the solution for all. When, in fact, equity, which is rooted in the principle of distributive justice or ‘concern with the apportionment of privileges, duties, and goods in consonance with the merits of the individual and in the best interest of society’, is what society should be striving for. Opportunities equally distributed do not address the individual needs and circumstances of a community. The notion of equality fails to appreciate the multidimensional systemic issues involving economic, social, cultural, historical, and political factors that unfairly advantage some groups and disadvantage others.”

“Political determinants of health involve the systematic process of structuring relationships, distributing resources, and administering power, operating simultaneously in ways that mutually reinforce or influence one another to shape opportunities that either advance health equity or exacerbate health inequities.”

[Devin Seyler · Rating 3 out of 5]

This book began by giving some important perspectives on the history of health equity in the US and then veered unexpectedly into an ad for Obamacare. I enjoyed learning about how the bill evolved and all the political drama involved in its passing and subsequent attempts to repeal it, but the author completely skipped over the implementation, and didn’t describe any of the impacts of the ACA, positive or negative.

[S.M. · Rating 1 out of 5]

Disclaimer: I'm not aligned with either political party, as they are both total garbage.

"Why is it that a country that uses so much health care has the lowest rate of health in the developed world?" Buddy, you just answered your own question! Eating pharmaceuticals and making trips to the hospital are not going to make a person healthy, probably the inverse.

As is illustrated with his deeply flawed tree allegory, Dawes seems to believe that people are never responsible for what happens to them in life because every misfortune or under-opportunity can be squarely blamed on someone else, and in this book's case, it's government. His claim is that the government needs to do more in the name of health equity. The problem with this idea is that it requires a government that actually holds its working class citizens' wellbeing as a concern. Well, you know what they say: just because you believe in it doesn't mean it exists. Dawes then reveals a study citing the main reason most people who do not vote refrain from doing so: their votes don't matter and the government does not work for them. He dubs these people Wrong. This guy must be living in a fantasy world, or at the very least residing comfortably in the wealthy class if he truly believes that. Plus, he strikes me as someone who actually WANTS a Nanny State.

Finally, the phrase "the political determinant(s) of health" comprises about 25% of the entire book's word count, like a kid's deliberately bloated book report. If you're anything like me, you consider mindless repetition a form of torture. Job well done here.

A tough book to get through, and dripping with liberal partisan sentiment. If you believe that there is nothing good about more government involvement in our lives, period, you probably won't like this book.

[Preethiya Sekar · Rating 4 out of 5]

The political determinants of health seem akin to Paul Farmer’s application of “structural violence” but further tailored to the American health policy context. Dawes provides a framework to think about how the social determinants of health were created and continually reinforced by policy-level decisions. The strengths of this book lies in its deep historical dives into major health policy-shaping moments (enjoyed the chapter on how the ACA was created and reshaped) and utilization of the socioecological model to highlight the different levels influencing health. I wish Dawes delineated which determinants were more important/urgent (i.e.: I would think lobbying/“commercial interests” would have an outsized impact but was not highlighted as much in the historical examples).

[Michael E · Rating 4 out of 5]

Strong history of the political history of health care in America plus a detailed recounting of the author's experience in the passing of the ACA. Less well developed is the 'model' for political determinants of health, which is descriptive but doesn't seem to offer a truly explanatory insight into the dynamics, which may unfortunately be simply as crude as the intersection of power and racism.

[Julia Prescott · Rating 4 out of 5]

This book laid a good theoretical framework and I wholeheartedly agree with Dawes’ assessment that we need to pay more attention to the political determinants of health as they are ultimately what influence the social determinants of health as well as other factors. I especially liked the model that Dawes’ lays out in this book that explains how voting, governmental and policy all shape these political determinants.
One thing that this book highlights that it can be generally categorized that there are 4 different arguments for health policy typically employed. This includes national security arguments, economic arguments, outcome arguments, and moral arguments. Unfortunately, it seems like moral arguments don’t cut it for the United States which is always so sickening to me. Why do we have to provide a monetary value of what money will be saved if a certain amount of people, usually historically oppressed groups, don’t die or live longer because they have health insurance coverage or access to a doctor. Why don’t people just act because it is horrible and unjust in the first place for people to be denied these fundamental needs. Why do people need to see a dollar amount? Also, I was not aware of all the arguments that have been used about national security in the past to try to improve health equity, so I definitely learned from that.
I think the first 3 chapters were definitely the best and although I learned from the ACA chapter I think the message could of been conveyed in a more concise way. Also, there’a only a really broad call to action without more specific reccomendation and but the message is clear and important: we need to keep fighting for health equity by challenging our political and legal structures that maintain the status quo and disadvantage so many. We need to fight to eliminate racism, classism, sexism, homophobia, ableism, and everything horrible that is entrenched in American politics in order to achieve optimal health for EVERYONE.

[Erica Li · Rating 4 out of 5]

This is definitely an interesting framework. I love more and more that in the field of public health we're diving into societal issues that have directly and indirectly harmed health outcomes in the U.S. ESPECIALLY for people of color.

I will be following Dawes throughout my career .

[Nikki Iamonaco · Rating 3 out of 5]

We hear so much about the social determinants of health it’s interesting to think about the political mechanisms that are behind them. Lots of interesting factoids but non fiction is always a bit hard to get through for me (including this one lol)

[Anam Azam · Rating 5 out of 5]

Talking about injustice and inequity between communities isn’t new for the world, it drives from ages and continues to perform tasks. But what this book does, splitter some light in-depth on the rotten structure of the healthcare, which had two faces, and showed up as per the community, people belong to.
The author not only talks highly about the political determinants of health but also the link of a garden with the country was simple and easier to understand that How to like some trees in the garden, some communities left unattended by the farmers/politicians/executives.

Demographic factors also play an important role to get good healthcare treatment, and executives will never be able to learn the issues from the roots until or unless the amount of the members of the congress remain the same because this way each member of the senate handle almost or more than million of people.

Dr. Dawes gave a brief moment for people to look through the issues, and their solutions, although there was something he brags about in vain, overall the book was a great way to get yourself treated with knowledge and awareness.

[Brenna Beltramo · Rating 2 out of 5]

This book could have been a bullet point timeline or a powerpoint slideshow.
It felt like a ridiculous amount of the word count was just listing all of the organizations that supported one specific policy or amendment or event.
While he makes some good points, most of those points are made within the first couple chapters and the rest is very drawn out. A great resource to pull quotes from on specific events, but it makes for a very, very dry read. Additionally, the verbiage he chooses makes it so I feel that if I didn't already agree with him that these trends exist in our society, he probably would not convince me of it. More specifically, the entire book is very left-wing and does not explain any right-wing points of view on the matter whatsoever. Quotes he pulls from Republican representatives are vague and do nothing to explain why they oppose the specific policies or ideas--whether the author agrees with them or not, it's useful to the reader to at least explain them. Otherwise, it just detracts from his own point--which it does.

[Jacquita · Rating 5 out of 5]

Great book!

As a second-year MPH student, this book really tied together the various parts that work in silos regarding health in our society. Using history as an example, Dawes does a wonderful job really thinking and digging deep into the causes of the causes of inequities in our society. He also explores how we get here, who got us here and more importantly, how do we reverse courses. Highly recommend for anyone interested in public health.

[tempest blanchard · Rating 5 out of 5]

Incredible read. Important and necessary for anyone studying/making policies.

[Bailey Griffen · Rating 4 out of 5]

Here, Dawes presents a digestible introduction to the political levers that shape our nation’s health. He provides a compelling argument that rather than dwelling on the social determinants of health, we should move further to we upstream to address the political actors that feed (or starve) everything downstream, from structural inequities to health outcomes. In short, he argues that politics holds the most influence over our wellbeing, or lack thereof.

While Dawes’ book is easily accessible to those without an extensive background in health policy, the structure of his book seems misplaced. In several instances, his interest in the details could easily allow the reader to lose site of the bigger picture. It would, perhaps, be more apt to call his book a history of the passage of the ACA. What was confusing, however, is that these details supported his thesis no more than other anecdotes that took up far less space. While Dawes presents compelling points, he does not offer readers the best organized read.

Due to no fault of his own, but I also wonder the extent to which those who disagree with Dawes would read his back. Even if they did, would they find it credible since he is so quick to make arguments down partisan lines? On a point as important as health, it seems critical that we find ways to speak across the aisle. One of his arguments on this point is the need to speak about health equity in terms of its economic burden and national security concerns. I wish he had elaborated more on this and discussed how this has proven efficacious (if at all) in the modern day.

Thoughts I had during my read:
-Where can citizens outside of government have our voices heard? Where will we make the biggest impact?
-How do we promote bipartisan discourse and engage in dialogue that works towards a common goal predicated on our similarities rather than our differences?

Quotes:
“Political determinants of health inequitably distribute social, medical, and other determinants and creat structural barriers to equity for population groups that lack power and privilege” (42)

“‘Times can blind us to certain truths, and later generations can see that laws once thought necessary and proper, in fact, serve only to oppress’” — Lawrence v Texas, 2003 (60)

“‘One of the unique and wonderful things about America has always been our self-reliance, our rugged individualism, our fierce defense of freedom and our healthy skepticism of government. And figuring out the appropriate size and role of government has always been a source of rigorous, and yes, sometimes angry debate. That’s our history.’” —Obama, 2009 (114)

“‘There’s greater satisfaction in respecting our differences but not letting them prevent agreements that don’t require abandonment of core principles, agreements made in good faith that help improve lives and protect the American people.’” — John McCain, 2017 (138)

[Scott Pearson · Rating 4 out of 5]

In scientific circles, the "social determinants of health" is a common phrase used to describe how one's zip code can have more impact on health outcomes than one's personal health. This book plays off that title by describing how America's political situation - whether one is part of a favored class or note - can influence health outcomes. It takes particular aim at health inequities in American history.

Daniel Dawes describes attempts in American history to provide a better, centrally organized healthcare system: namely, under Franklin Pierce and with the Freedman's Bureau after the Civil War. Both attempts, sadly, did not induce lasting change. Harry Truman and Bill Clinton failed to produce Congressional legislation to pass into law.

In recent years, Barack Obama did succeed in passing the Affordable Care Act, more commonly known as Obamacare. That legislation imperfectly sought to address health inequities that might produce a less healthy workforce or extra, unnecessary expenditures on the system. Of course, Republicans sought to repeal and replace that legislation for the next decade, but largely failed in their efforts. Dawes concludes by describing the future of work in health inequities. This book preceded the second Trump administration and how research work in health inequities has been suppressed. Thus, the story of the political determinants of health is ongoing.

I appreciated a look at the politics surrounding healthcare. Make no mistake, though: This book is a work of political science more than public health. I would have liked to have heard more stories about how politics affected lives outside of Washington. That integrative work describing a transformation of American culture still awaits us - as does a lasting resolution to today's health care debates. I'm not sure Obamacare represented as much of a long-term new paradigm as a first foray into health reform. Given that health has been considered a "third rail" of American politics, I believe continued bipartisan conversations about this issue are necessary for a better system. Perhaps only then can the "general welfare" of the American people's health be realized in a less controversial and less passion-filled manner. I can only hope that health inequities will play a significant role in that resolution.

[Laura · Rating 5 out of 5]

In public health, we talk about how important it is to understand what causes the causes of poor health, or to understand the social, economic, and environmental factors that make it difficult for people to be healthy. So many books have been written about the social determinants of health, and we've unpacked how food deserts, environmental hazards, residential segregation, and other phenomena drive chronic disease. But in this book, Dawes takes us even further upstream, to understand what causes the causes of the causes. He illustrates how voting, government, and policy contribute to the social determinants of health, and illustrates how advocacy can leverage these political determinants of health. The case study examples show how health equity advocates worked to get health equity on the agenda throughout the debate about healthcare reform, from the 2008 presidential campaign to the passage of the Affordable Care Act in 2010. A great read, and a great adjunct to the vast social science and public health literature on the social determinants of health.

[Emily · Rating 4 out of 5]

This book gave me so many mixed emotions. Frustration, a little boredom, anger, and hope. These were tied to the realities, the apathies, and the many "-isms"(racism, sexism, ableism, etc) tied to the American political system.

Dawes stories and anecdotes were good building blocks for understanding how the places we live, work, and grow as well as the policies and systems that govern those factors have incredible impact on health outcomes - for better or for worse.

The middle section was a love letter to the ACA, which was a huge win for health equity and gaining access to health care for millions. But it was very dense, very laden down with the names, committees involved etc and Dawes himself admits that insurance/access to healthcare is only a small part in determining overall health. I wish more time had been spent looking at the everyday conditions that cause health disparities and ways people are addressing it in their states, cities and community.

Overall, good if frustrating look at the Political Determinants of Health.

[Julia · Rating 4 out of 5]

To prime the audience in understanding what political determinants of health, Dawes, instead of explicitly defining what the term is, regales the audience with a story about a farmer with two different flowers experiencing two different environmental conditions. This was artfully done to set up the audience for his didactic sections.

Dawes does a wonderful job categorizing different factors of the political determinants of health into discrete categories that the reader can conceptualize. Each chapter reflects these 4 cores. His usage of mind maps and diagrams also helps simplify these esoteric and complex concepts that he presents in the bureaucratic process.

However, there are WAY too many actors, policies, and names that are not clearly defined that makes the book a bit confusing. Dawes could have bettered the book by not listing the entire party members involved in a certain policy, but by defining these characters first so we can help categorize who does what. Dawes only failure in this book is his fangled writing that foments frustration.

[Gina · Rating 2 out of 5]

Although I believe this book is well intentioned, I think the author is clearly aligned with one political party while demonizing the other. As a country this tactic is not working. We have to come to terms that there are multiple sides and we have to listen and discuss.

Also, our government is large and cumbersome and should not be the primary solution. I do believe policy and government have their place but to expect the care of all the poor and needy from the government is unrealistic.

As a Healthcare worker I know that there are many things in place already to serve underprivileged populations, but the human resources are low and declining.

I could say a lot more, but I will just reiterate that although well-intentioned I believe this book misses the mark and misses a lot of important variables without which real solutions can't be discovered.

[Doc · Rating 5 out of 5]

Dawe's does a great job with showing how achieving health equity for all Americans has been a long battle with wins and losses along the way. While not be of interest to a general audience, the book is essential reading for those interested in social and health policy, and for health equity advocates.

Of particular use is throughout chapters, Dawes explains the strategies that have been successful in advancing equity. We learn what worked and what didn't work. It's also a sobering reminder for folks who say "I don't follow politics," that though you're not paying attention to it, it follows you!

[Lee Radford · Rating 2 out of 5]

If we want a better health care system, we need to vote for candidates who want a better health care system. Until we vote for candidates who want a better health care system, we will not get a better health care system. There you go. Now you do not have to read this book, which does not really provide a way for American to make any change on these points. It does provide a history of how social equity advocates used their influence to shape the 2009 Affordable Care Act, but that still does not explain how to get votes for candidates who want a better health care system.

[Louise Miller · Rating 5 out of 5]

Interesting and well paced! The author outlined the political determinants of health and how they affect public policy and people very well. If you're used to primarily academic non-fiction books he may seem a little pushy but I'd hope it is apparent that the book is intended to also call the reader to action for public health. I enjoyed learning so much about the history of American advocates push for better public health policy. Frankly, Luigi Mangione being in the news so much this week inspired me to move this from my TBR pile and actually start it.

[Emily Frueh · Rating 3 out of 5]

I would say this book is a great starting place for someone who is unfamiliar with SDOH. For those who work in public health/health policy, the content wasn’t much “new”, seems rather straight forward. Very interesting if you are wanting to learn more about ACA. There were sections I appreciated and am glad I read it overall. I felt it also reads like an academic paper more than a book, but appreciated the author’s clear transitions.

[Griffin Onderchain · Rating 4 out of 5]

This book really opened my eyes to how complicated and how pendulum-esque political influence on the American healthcare system is and has been in the past. Somehow this book made me both marvel at how far we’ve come and constantly recoil at the deep flaws which still exist in our current system. This book is full of great, citable information and is worth while for anyone who cares about healthcare at any level.

[Tim Mcleod · Rating 2 out of 5]

Profoundly disappointed in this slim volume, which frames 'PDoH' as near-exclusively constrained to electoralism, and paints Congressional oligarchs as champions of health equity. If you are looking for an account of health policymaking that reads less like the White House patting itself on the back , I recommend Governing Health: The Politics of Health Policy by Weissert and Weissert instead.

[Naz Z · Rating 4 out of 5]

Med school read! Mostly self explanatory if you’ve taken sociology, but necessary for all, especially those looking to work in healthcare, government, educations, any sectors that impact the lives of all people. I truly had not heard of political determinants of health in any of my classes, so that was also interesting to learn about, to really see how it ties into everything.

[André Harris · Rating 5 out of 5]

Finally finished reading @DanielEDawes’ book #ThePoliticalDeterminantsofHealth! This book is phenomenally written. As a health equity scholar and advocate, I gained a framework and a perspective to include in my future advocacy, policy and research work... ✊🏾✊🏾✊🏾 (from Twitter)

[Su Neyman · Rating 4 out of 5]

What a digestible breakdown of health policy in the US! I love that Dawes highlighted both successes and failures throughout history. 4 stars because I wish he would’ve added an additional chapter on strategies for advocacy.

[Elizabeth · Rating 3 out of 5]

The core argument makes sense and there’s some valuable documentation of the fight to pass and retain the Affordable Care Act, but the book is kind of a mess. The argument is underdeveloped and rambling.

[Dave · Rating 3 out of 5]

Really two different books. A useful framework for system thinking around health equity and outcomes, and then what felt like a recycling of a dissertation or white paper about the history of the Affordable Care Act, with a very loose connection between the two.

[Dyanna · Rating 4 out of 5]

An important topic and one covered well in my public health degree program but save some time and money and google a journal article by Dawes. There is nothing more significant in this book that what has already been written by him in other media. Lots of fluff in this version.