Daniel E. Dawes began his 2020 book, “The Political Determinants of Health,” with a story about a farmer looking for land to plant an orchard. He finds a plot of land split into three sections: one with rocky soil, one with poor soil, and one with rich soil.
In the story, the farmer planted fruit trees in all three sections of his newly acquired land. As you can probably guess, the trees in the rich soil grew fast and strong, producing abundant fruit while the trees in the other two sections struggled, withered, and died off.
While the trees’ outcomes could be attributed to their respective soil conditions, location wasn’t the only factor at play. The farmer paid extra attention to the best-performing trees; the ones planted in the fertile soil. Because the trees in the other sections didn’t grow as fast or as strong, he paid less attention to them and provided them with less care.
Dawes’ lesson from this story is that people’s health outcomes are often based on limited choices and opportunities. Each tree planted had the same innate function: to grow and bear fruit. The trees that died didn’t decide they wanted to be unhealthy. Rather, they succumbed to a lack of resources in their immediate surroundings.
In this story, the farmer is a stand-in for the role of a government. From there, Dawes expands into a new framework for understanding health outcomes, equity, and the inequities that plague health care in America.
What are the “Political Determinants of Health”?
The political determinants of health are an attempt to explain the various ways that politics – voting, government, and policy – create the social drivers of health and impact actual health outcomes, access to care, and more.
Dawes is a public health policy expert, educator, researcher, and executive director of the Satcher Health Leadership Institute at the Morehouse School of Medicine. His “Allegory of the Orchard” is the foundation for his political determinants of health model.
The political determinants of health can be broken into three categories: voting, government, and policy. According to the Satcher Institute, “The 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.”
Image source: Daniel E. Dawes (2020), The Political Determinants of Health, John Hopkins University Press
An Argument for Multiple Approaches
Advocacy groups and health care organizations that seek to resolve existing inequities often fall into one of two buckets: those that seek to impact policy and other structural forces; and those that seek to directly allocate resources to those in need.
The political determinants of health illustrate the important fact that little can be done to permanently resolve inequities if overarching structures are not changed. However, that doesn’t mean organizations seeking structural policy change have the only “right” answers. Systems change takes a long time, and people experiencing health inequities need help now.
Resource Allocation
That’s where resource allocation comes in. Providing low-cost health care, transportation services, free equipment, and other means of direct aid are equally necessary, even if they don’t address the root causes of inequity.
As health advocates work to create more equitable systems, organizations can work together to find a balance, meeting immediate needs on one hand while influencing policy and creating structural change on the other.
Addressing the Political Determinants of Oral Health
As NCOHC and our partners work to build a more equitable oral health system, policy will continue to play a leading role. Understanding the interaction between the political determinants of health and the social drivers of health also underscores the need for a diverse coalition of advocates working toward these structural changes.
Policy changes that range from specific, targeted reforms allowing hygienists to fill all the roles they are trained for to broader updates to the Medicaid structure are necessary to increase access to care across the state. However, reforming the Dental Practice Act isn’t the only thing that can be done to impact oral health. Affordable housing, fair wages, and healthy food advocacy will also impact oral health, and vice versa.
The bottom line is that everyone, everywhere has a role to play in creating better systems, and all those roles, no matter how niche, fit into a network of advocacy that must work together if we are to succeed in creating a better future for all North Carolinians.
NCOHC, a program of the Foundation for Health Leadership & Innovation, works to advance systems-level changes, improving the overall health and well-being of all North Carolinians by increasing access and equity in care. To stay up-to-date and get involved, join us today as a North Carolinian for Change.
