“Two intersecting and interdependent systems comprise democracy in the United States,” Eileen Salinsky, Program Advisor with Grantmakers in Health, wrote in a compelling essay in April 2022. Those systems are, Eileen described,

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

Civic Engagement is a Social Determinant of Health, Eileen titled this piece in which she discusses philanthropy’s role in both strengthening democracy and bolstering public health.

Today is Election Day in the U.S. The timing is the mid-terms, the political races that happen in-between the Presidential Elections. The estimate of cash that will have been spent in these political contests together is about $17 billion, a record high.

If you have the right to vote in the U.S. — and I hope you did or do today — regardless of your party ID or political orientation — we are in the midst of some of the highest degree political stress in America ever quantified by the American Psychological Association. APA found in its October 2022 Stress in America study that many Americans are so stressed, they cannot function.







Most Americans don’t feel the government cares about them, nor do most feel protected by U.S. laws.

As we reflect on this sad state of our feelings of community in the U.S., let’s turn to PACE which defines “civic engagement” as “helping people be active participants in building and strengthening their communities, whether defined as a place or a shared identity or interest.”

Eileen reminds us that voting is among the most visible expression of active participation in democracy. But she reminds us that one-third of eligible U.S. voters did not vote in the 2020 presidential election, pointing to structural barriers such as onerous voter registration requirements, inflexible voting hours, long lines in polling locations, and cynicism about government which can be dispiriting to some voters.









It is important to note that some of these structural barriers are parallel to some peoples’ lack of access to health insurance. A research paper in The Lancet Regional Health for the Americas, published in October 2021, provided evidence for this in their report, Barriers to Voting and Access to Health Insurance Among US Adults: A Cross-Sectional Study. The researchers examined data for 242,727 adults in the 50 states and Washington, DC, quantifying access to voting and various demographic characteristics — including the odds of being uninsured.

The conclusion: that “groups commonly targeted by voting restriction laws — those with low incomes, who are racial minorities, and who are young — are also less likely to be insured in states with more voting restrictions.” The authors further point out that the resulting disproportionate access to health care can also explain disparities in other health outcomes such as chronic and infectious disease (e.g., disproportionate risks to mortality due to complications from COVID-19, which I discussed here in Health Populi).









Health Populi’s Hot Points:  Risks to the drivers of health (or social determinants) travel in groups: if one is at risk for one SDoH factors, such as lacking health insurance, then one is likely to have other risks on well-being — such as access to healthy food (whether due to living in a ZIP code with food deserts, or lacking sufficient income to afford fresh produce), transportation, or clean air or water.

I wrote my book, Health Citizenship, in 2020, six months into the emergence of the COVID-19 pandemic in 2020. We could already witness health inequities due to lack of access to health care or ability to work from home based on SDoH factors.

As we muddle through what will be stressful and divisive 2022 midterms, I revisit the four pillars of Health Citizenship I detailed in my book — that healthcare should be a right for all health citizens in the U.S., that privacy and security as well as access to our personal and health information is essential, that trust in our institutions is a precursor to civic and health engagement, and that we reimagine a new social contract of civility and — I daresay — Love for one another.

In the immediate moment of political stress, I realize that’s an audacious ask and prayer.

But I’ll persist in calling out all of our rights and responsibilities for being full on health citizens in the U.S., and around the world.