In this paper, we explore how primary care physicians and organizations can better support patients and communities to engage in our democracy and build healthy public policy. Democratic engagement and health are undoubtedly a new area for family medicine, but not without precedent.
In 1849, German pathologist Dr Rudolf Virchow stunned the medical establishment. Commissioned to investigate a typhus epidemic in Upper Silesia, a poor rural area of ethnic Poles, his recommendations included the extension of full and unlimited democracy in the region to improve health.1 A century later in 1964, at the height of the civil rights movement, Dr Jack Geiger travelled to Mississippi. In an effort to fight against segregationist “Jim Crow” laws, he provided medical care to support the mobilization and registration of African American voters. This work led to the development of the community health centre movement.2
Democratic engagement is also present in Canada’s health sector. A number of Canadian physicians, nurses, midwives, and other providers are working to influence public policy. In 2012, following cuts to the Interim Federal Health Program for refugees, Canadian Doctors for Refugee Care quickly formed and engaged in a sustained campaign of protest, research, and advocacy until the changes were reversed.3 The Canadian Association of Physicians for the Environment is engaged in a campaign to support carbon pricing and phase out coal power to mitigate the health consequences of climate change.4 Canadian Doctors for Medicare is pressing federal legislators to expand Medicare to include access to prescription drugs,5 whereas the nascent Doctors for Protection from Guns is pushing the public and politicians to ban handguns and assault weapons in Canada.6
Democratic engagement is associated with health
According to the Canadian Index of Wellbeing, democratic engagement happens when
citizens participate in political activities, express political views, and foster political knowledge; where governments build relationships, trust, shared responsibility, and participation opportunities with citizens; and where citizens, governments, and civil society uphold democratic values at local, provincial, and national levels.7
This could include voting, running for office, being involved in political parties, providing public or media commentary, meeting with policy makers, taking part in budget decisions, or discussing political issues among peers.
Democratic engagement varies across the population and is associated with socioeconomic status. Voters who are low-income or disadvantaged in other ways, such as in employment status or educational attainment, consistently have lower rates of voting than their high-income, privileged peers.8 Hypotheses to explain this association have included insufficient time for engagement because of employment, lack of awareness, and feelings of disengagement from the broader political process.9 Democratic engagement is also related to health status. Canadian data from the 2011 federal election show a positive association between self-rated health and national electoral participation.10 The same phenomenon was seen between mental health and Canadian municipal elections.10 State-level American election data showed that socioeconomic inequality in voter turnout is associated with poor self-rated health.11 Studies from Britain,12 Norway,13 Sweden,14 and Russia15 found the same association between self-rated health and electoral participation; those who are in better health are more likely to vote. Those with disabilities,16,17 depression,18 alcohol use disorder, or dementia19 are less likely to vote. Although these associations exist, the direction of voting and health is unclear and is likely bidirectional. Nonetheless, there are hypotheses with respect to causality. For example, in addition to the debilitating nature of the aforementioned conditions, they might also affect how individuals connect with society and, as a result, affect their engagement in political processes such as voting. Of interest, those with cancer have a strong positive association with voting. It has been hypothesized that cancer associations provide venues for social mobilization and political participation.19
These associations persist across the lifespan. Civic engagement during late adolescence and early adulthood are positively associated with higher income and educational attainment. In particular, voting and volunteering are especially favourably associated with good mental health and positive health behaviour.20
Differential democratic engagement has consequences
Differences in political engagement result in policy that is focused on the interests of groups that are most engaged, rather than groups with the greatest need.15,21,22 In other words, policy makers and politicians are disincentivized to respond to communities that do not vote or engage in the political process.23 Public policies that affect the social determinants of health, such as affordable housing, income security, and access to decent work, are all shaped by those voters who engage at a high rate.
Primary care can support voter engagement
Given the link between health and political participation at both the individual and population levels, how can primary care organizations support more disadvantaged groups to engage? Social workers have called for the development, implementation, and evaluation of interventions that increase civic engagement opportunities among older adults.24 Nursing scholars have called on their peers to be aware of patients’ voting rights and to help exercise them.25 Others have encouraged the facilitation of postal or proxy voting for those admitted to hospital and unable to vote in person.26 The question remains: what is the role of family physicians?
Family physicians see patients as they suffer the economic and social consequences of poor health.27 The College of Family Physicians of Canada calls on family doctors to serve as “a resource to their community, assess[ing] and respond[ing] to the needs of the communities or populations served by advocating with them as active partners for system-level change in a socially accountable manner.”28 On democratic engagement, the Canadian Association of Community Health Centres has affirmed
the fundamental role of Community Health Centres as civic agencies which not only provide high-quality healthcare services and programs, but also programs and initiatives that explicitly seek to improve Democratic Engagement as a key determinant of individual, family and population health.29
Like the American community health centre movement, the perspective of Canadian community health centres is informed by an explicit mandate to address social determinants of health, a perspective now gaining traction in primary care more broadly.30
Beyond declarative statements, primary care organizations aiming to improve democratic engagement can pursue education, intervention, collaboration, and evaluation. Health care organizations should develop training requirements and courses for interprofessional health care students to not only better understand the social determinants of health and democratic engagement, but to learn how to take action. Successful interprofessional courses have a real effect.31 New courses should provide training in practical community-based action.32
What could interventions look like on a local level? In New York, NY, 2 university-affiliated family medicine clinics undertook a clinician-led voter registration drive to increase the participation of communities often under-represented in the electoral process. Interdisciplinary health personnel were recruited as volunteers and trained. Then they ran a 2.5-month voter registration booth in all areas of the health centre that focused on providing non-partisan voting law information and registering patients to vote. Among patients who were eligible to vote but were not registered, 89% registered to vote, most of whom were aged younger than 40 years or were first-time voters.33
Primary care organizations can be involved in further research to examine how participation in elections is linked to social isolation, poverty, education, and health outcomes. Barriers to voting for disadvantaged people who have contact with health services could be reduced by hosting polling booths in clinics or hospitals. Health care organizations have already hosted “voter pop-ups” that help demystify the voting process through simulation and explanation.34 During elections, organizations could collaborate to host non-partisan town hall meetings for candidates to share their positions on health care and social determinants of health. Similarly, health organizations could release health-focused, non-partisan platform scorecards, something many health-focused groups are beginning to do.35–37
Between elections, primary care organizations could encourage patients to engage in deputations to municipal, provincial, territorial, and federal levels of government, or in participatory budget processes. Training could be provided for patients to connect with local legislators such as city councillors, elected provincial representatives, or Members of Parliament.
Discussion
Primary care organizations and family physicians are increasingly being asked to do more, as our understanding of the social determinants of health improves. They cannot take on these new tasks alone and should not work in isolation. Canada is fortunate to have a vibrant community focused on democratic engagement, including the Democratic Engagement Exchange at Ryerson University in Toronto, Ont; Inspire Democracy; and Elections Canada.38 There are also many active local organizations. The Dartmouth North Community Food Centre in Nova Scotia tripled local voter turnout in 2016 through an 8-week campaign that included practice pop-up voting stations, a candidate meet-and-greet, and community voting day parade.39
As this represents a new area of work for primary care, collaborating with local organizations will be critical for health care organizations to build trust with the community and operate sustainably. For example, the St Michael’s Hospital Academic Family Health Team in Toronto has built a Health Justice Program in partnership with local legal aid clinics.40 This concept was imported from the United States, where physicians and lawyers first teamed up to take advantage of their respective areas of expertise and relationships with patients and clients.41
Clinics should experiment with such targeted interventions and assess their effectiveness to establish a body of practical experience from which we can build on lessons learned and create broader guidelines. This can go beyond elections and political platforms to include community organizing. It will not be a panacea for policy change, as social change is often achieved outside the conventional activities of democratic engagement, such as voting or meeting with elected representatives. Nonetheless, as our understanding of social determinants of health expands, we are only just starting to touch on the underlying drivers of health—the “determinants of the determinants.”
Footnotes
Competing interests
Dr Raza is Volunteer Chair of the Board of Canadian Doctors for Medicare.
The opinions expressed in commentaries are those of the authors. Publication does not imply endorsement by the College of Family Physicians of Canada.
This article has been peer reviewed.
Cet article se trouve aussi en français à la page 644.
- Copyright© the College of Family Physicians of Canada
References
In this issue
