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Health-based civic engagement is a professional responsibility

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To the Editor — Since the 2020 US presidential election, there has been a nationwide assault on voting rights, with 18 states enacting 30 new laws that restrict voting access, and hundreds of similar bills marching through state legislatures1. Recent restrictions draw comparisons with the literacy tests and poll taxes of the Jim Crow era. Indeed, much of this voter suppression is targeted toward Black people and Indigenous Americans and people of color, all of whom have long borne the violent burden of institutionalized racism and are survivors of extensive, punitive disparities in all areas of life. Health professionals must champion patients’ right to vote to protect health and deracinate inequitable medical practices, building on the efforts of organizations such as VotER and VoteHealth 2020.

The interdependency between voting and health, as well as the power of policy to address social determinants of health, underscore why civic-health promotion must become a professional responsibility for healthcare workers. From registering to vote to attending neighborhood town halls to engaging government representatives, civic health refers to the ability of a community to come together and address public concerns. Civic health is a powerful indicator of overall health, with lower voting rates consistently associated with poorer health; for instance, patients with chronic illnesses are less likely to vote than healthy individuals2. Civic and health engagement amplify and reciprocate one another, with longitudinal studies demonstrating bidirectional causal pathways.

Voting also impacts community health because local elections determine how vital resources are made available, from healthy food to potential employment opportunities. In 2015, Louisiana’s Governor John Edwards campaigned significantly on Medicaid expansion, and his election profoundly bolstered insurance enrolment rates and self-reported health among Black residents in the state3. As such, civic engagement in vulnerable, disadvantaged communities can contribute to the development of more equitable public policy.

Given that 80% of modifiable contributors to patient health are determined by nonmedical factors4, empowering patients to vote allows them to exert agency over their health. Voter registration of all patients, whether hospital patients, outpatients or people visiting their community health centers, offers the opportunity to address underlying political determinants of health, such as special interests, partisan ideologies and policy more broadly. Voter engagement also helps address long-standing, systemic inequities in medicine. One study found that almost 20 state-level elections from 1970–2004 may have had a different outcome if Black people of voting age had the same mortality profile as their white counterparts2. Such health inequities silence underrepresented voices and are a challenge to democracy; thus, voting disparities must be addressed in tandem with health disparities. The medical community should reimagine health interactions such that questions like “do you smoke?” and “are you exercising?” are naturally accompanied by “are you registered to vote?” Promoting patients’ civic involvement will promote equity and their overall health.

Traditionally, the Department of Motor Vehicles has served as the primary venue for voter registration, but the National Voter Registration Act encourages nonpartisan voter education and registration activities within hospital settings as well. Given the frequency of hospital utilization among underserved communities and emergency departments’ increasing role as safety nets5, healthcare settings are innovative locations to register people to vote. Indeed, hospitals have access to the groups least likely to be registered to vote (including younger adults, low-income individuals and Black and Indigenous people)6 and offer trusted messengers in a system in which trust is deeply frayed. Trust has been damaged over many decades of systemic racism, from denying Indigenous Americans the right to vote until the 1924 Snyder Act to the effective disenfranchisement of Black Americans with Jim Crow laws. Rebuilding trust in democratic systems will require healthcare workers, some of the most trusted professionals in society, to use their positions to advocate for civic engagement.

Over 300 hospitals and care organizations have sought to promote such voter access and advance healthcare-based voter registration through National Civic Health Month in August, hosting voter registration drives, displaying posters with voting resources and facilitating conversations among patients about civic engagement7,8. One example is VotER, a nonpartisan nonprofit that helped over 46,000 patients vote in the 2020 election through sending healthcare professionals Healthy Democracy kits. Each kit consists of a highly visible lanyard and badge backer with a QR code to scan or number to text so that patients can check their voter registration status and register to vote within minutes (Fig. 1). With “Ready to Vote?” or “Register to Vote Here” lining the badge-backer’s side, patients’ curiosity empowers healthcare workers to triage them to the VotER website, where patients can receive local voter registration information, text reminders on when and how to vote, and an option to speak with a voting rights expert at any time. Having delivered over 26,000 Healthy Democracy kits, VotER enables care professionals across all role groups and specialties to deconstruct the obstacle course that has long characterized voting in the United States and thereby include all patients in the democratic process.

Fig. 1: The VotER healthy democracy kit.
figure 1

Image taken with permission from VotER.

The image shows the VotER healthy democracy kit, including the lanyard and ID badge backer.

The civic health movement includes countless other initiatives that seek to facilitate the civic engagement of patients. Democracy at Discharge, for instance, registers patients to vote as a part of their discharge instructions, alongside the treatment and follow-up plan. Another voter registration drive in Bronx hospitals saw clinic personnel engage patients during appointment registration, before the physician visit and in other waiting periods to educate them about New York voting laws and, if patients were interested and eligible, register them to vote. Eighty-nine percent of previously unregistered patients were registered to vote, demonstrating how clinics are “powerful vehicles for bringing a voice to civically disenfranchised communities9.” The organization VoteHealth 2020 emerged from this effort, with badge stickers, email signatures and premade flyers for healthcare workers to unobtrusively build awareness and promote voter registration. Other strategies by civic-health organizations aim to normalize voter registration during other common waiting times, such as during the COVID-19 vaccine observation period and in regular preventive health interactions, such as during receipt of the annual influenza vaccine. Supporting patients’ right to vote and holistically addressing their medical needs can be built on the synergy between civic and health engagement.

The responsibility to combat voter disenfranchisement must, in part, fall on the shoulders of healthcare professionals. As witnesses to devastating health inequities, healthcare workers have an ethical and professional obligation to deracinate the root causes of these disparities. Whether through individual efforts or in partnership with civic-health organizations, care professionals must help build a healthier future for all by empowering patients to have a voice in the policies affecting their wellbeing. The path to equity and improved health can be paved through physicians promoting their patients’ right to vote.

References

  1. Voting Laws Roundup: July 2021. Brennan Center for Justice https://www.brennancenter.org/our-work/research-reports/voting-laws-roundup-july-2021 (2021).

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Acknowledgements

F.C.S. received funding from National Institutes of Health and Massachusetts General Hospital Executive Committee on Research, National Institutes of Health NIDDK P30 DK040561 and L30 DK118710.

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S.S.B. drafted the initial manuscript. A.F.M. and F.C.S. provided mentorship and editorial support. All authors read and approved the final draft before submission.

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Correspondence to Fatima Cody Stanford.

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A.F.M. is the founder and executive director of VotER. The other authors declare no competing interests.

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Bajaj, S.S., Martin, A.F. & Stanford, F.C. Health-based civic engagement is a professional responsibility. Nat Med 27, 1661–1663 (2021). https://doi.org/10.1038/s41591-021-01523-2

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