'People in the audience were asking better questions than I was'

Voting is often viewed through the lens of civic duty and political engagement, but its implications stretch far beyond the ballot box. Voting plays a crucial role in shaping the social determinants of health (SDOH) - the conditions in which people are born, grow, live, work, and age. Understanding how voting influences health outcomes can help illuminate the pathways through which civic engagement impacts community well-being.

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The medical community increasingly acknowledges voting as a crucial SDOH, framing it as a significant public health concern. This relationship between voting and health is reciprocal: a person's health can impact their ability to vote, while the act of voting can also impact health outcomes.

SDOH encompasses factors such as income, access to nutritious food, reliable transportation, and safe and affordable housing -all critical components of these non-medical determinants that shape healthcare outcomes. Addressing these social factors is essential for improving overall health and ensuring equitable access to health care for all individuals.

Physician's Weekly groups the SDOH into five domains influencing health: Economic Stability, Education Access and Quality, Healthcare Access and Quality, Neighborhood and Built Environment, and Social and Community Context.

In 2022, the American Medical Association made a significant move by passing a resolution recognizing voting as a social determinant of health. This acknowledgment highlights the critical intersection between civic engagement and health outcomes, emphasizing that access to voting can influence various health determinants and ultimately affect individual and community health.

Emory University medical and Ph.D. student Jasmin Eatman was part of the effort to update AMA's policy. "School children are being murdered by weapons of war. Women are being forced to surrender their very own bodies to the state.

In some places, providing water to an individual waiting in line to vote can earn you jail time," said Eatman, speaking on behalf of the Minority Affairs Section, which authored the resolution.

"Despite these undemocratic efforts, we believe that there's still power in the ballot" and that social inequity can be tackled, even "transformed," by voter participation, she stated.

The connection between voting and health outcomes

Voting enables individuals to influence policies that directly affect healthcare access, funding for public health initiatives, and regulations that impact the environment. For instance, local elections can determine hospital funding, mental health services, and community health programs. When communities elect representatives who prioritize health, they are more likely to see improvements in health services and resources.

"Fair and constructive policy advancements fundamentally depend on a healthy democracy," writes Eileen Salinsky, program advisor for Grantmakers In Health. In "Civic Engagement Is a Social Determinant of Health," Salinsky determines there are two intersecting and interdependent systems that comprise democracy in the United States:

• A political system of representative government, which includes the legislative, executive, and judicial branches at the federal, state, and local levels.
• A collective system of self-governance, which includes how individuals interact with each other and their political system through many forms of civic engagement.

Voting is a form of civic engagement that often leads to greater community mobilization. When communities come together to vote, they also tend to organize around health-related issues, advocate for necessary changes, and push for resources to improve overall health. Grassroots movements that emerge from voter engagement can lead to significant health benefits, such as increased access to healthy food, better housing conditions, and improved public safety.

The demographic makeup of voters has direct consequences for health equity. Communities that are underrepresented in the electoral process often face disparities in health outcomes. When marginalized groups - such as racial and ethnic minorities, low-income individuals, and young people - fail to vote, their specific health needs may be overlooked in policy discussions. Ensuring that all voices are heard in the electoral process is essential for addressing health disparities and promoting equity.

Participating in elections can foster a sense of belonging and social cohesion within communities. When individuals feel they have a stake in their community's future, they are more likely to engage in collective actions that benefit public health. This sense of community can lead to stronger social networks, which have been shown to improve mental health and overall well-being.

Voting is not just about casting a ballot but also about understanding the issues at stake. Increased civic literacy can empower individuals to advocate for their health needs and rights. When people are informed about the policies that affect their health, they are more likely to engage in discussions, advocate for change, and hold their elected officials accountable.

Challenges to voting as a social determinant of health

While voting has the potential to influence health outcomes significantly, several challenges impede equitable participation in the electoral process. Understanding these barriers is crucial for developing strategies to enhance voter engagement, particularly in communities that face health disparities.

Many individuals encounter logistical barriers that make voting difficult. This can include:

• Physical accessibility: Polling places may not be equipped to accommodate individuals with disabilities, making it challenging for them to cast their votes.

• Transportation: Getting to polling locations can be a significant hurdle for people in rural or underserved urban areas, particularly for those without reliable transportation.

• Language barriers: Non-English speakers may struggle to understand ballots or the voting process, deterring them from participating.

Voter suppression tactics disproportionately affect marginalized communities and can take several forms. Strict identification requirements can disenfranchise those who lack the necessary documentation, often impacting low-income individuals and people of color. Aggressive purging of voter registration lists can lead to eligible voters being removed, especially in communities with high mobility rates. Insufficient polling hours or reduced access to early voting can hinder participation for those with rigid work schedules or caregiving responsibilities.

Economic factors can also play a significant role in voting participation. Individuals working multiple jobs or facing economic pressures may find it challenging to allocate time for voting, especially if they must travel long distances to polling places. Lower levels of education can correlate with decreased civic engagement and awareness of the importance of voting, leading to lower voter turnout.

Many potential voters may feel disillusioned with the political process. A perceived lack of responsiveness from elected officials can lead to feelings of hopelessness and disengagement from the electoral process. Increasingly polarized political environments can discourage participation, as individuals may feel that their votes do not count or that the system is rigged. Health issues can also prevent individuals from voting.

The Mi Familia Vota v. Fontes case is particularly relevant in this context as it addresses voting rights in Arizona. The suit challenges an Arizona law that mandates individuals registering to vote must provide documentary proof of citizenship, such as a birth certificate or passport, to be eligible to vote in federal elections. This law has raised concerns about accessibility and inclusivity in the voting process, potentially disenfranchising eligible voters who may not possess the required documentation.

In response to this legislation, organizations, including the League of Women Voters of the United States, the League of Women Voters of Arizona, the Secure Families Initiative, and the Modern Military Association of America, submitted an amicus brief in August to support the challenge against the law. Their brief counters arguments made by Arizona legislators and the Republican National Committee, which claimed that Congress lacks the authority to regulate presidential elections, thus allowing state legislatures to impose such requirements.

The 9th U.S. Circuit Court's ruling to strike down the provision in September 2023 reflects ongoing legal battles over voting rights and the implications of such laws on public health. By framing voting as a social determinant of health, advocates argue that restrictive voting laws not only threaten democratic participation but also exacerbate health disparities by limiting access to the political process, which is essential for addressing community health needs and resources.

"Arizonans need to know that HB 2492 is an intimidation tactic," said Pinny Sheoran, president of the League of Women Voters of Arizona. "Requiring proof of citizenship, a solution in search of a problem, will allow the state to further suppress voters, especially voters of color. There is no reason to make voter registration more difficult by not allowing voters to use the state form to register for federal-only elections. LWV Arizona will continue to stand up for voters and fight laws that do not serve the best interest of Arizona voters."

This case underscores the importance of protecting voting rights, especially in ensuring equitable access to health resources and fostering healthier communities. The intersection of voting rights and health equity will likely remain a focal point in public health discussions and legal challenges moving forward.

In recent years, researchers, policymakers, and health advocates have given considerable attention to the relationship between democracy and public health. While various factors such as genetics, lifestyle choices, and access to health care play significant roles in determining health outcomes, the political environment in which individuals reside is also a critical influence.

Democratic systems typically emphasize citizen engagement and accountability, which can lead to the development of more effective healthcare policies and practices. In democracies, governments are more likely to be answerable for delivering quality healthcare services. Citizens have the opportunity to express their concerns, advocate for their rights, and push for enhancements in health services.

Empowering communities to engage in decision-making processes is vital to improving health outcomes.

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