Health Equity Requires Civic Engagement: A Call to Action

Authors: Stella Safo, MD, MPH, and Eileen Barrett, MD, MPH

Keywords: civic engagement, health equity, advocacy, public health

In a time when little feels apolitical, most would agree that every person has a right to achieve optimal health. One pathway to achieve improved health for all is by centering equity in health care delivery. The focus on health equity became more pronounced after the racial reckoning of the summer of 2020 and its resultant commitment from individuals, institutions, and companies to dismantle systemic inequities in medicine. We saw widespread support statements and an unprecedented investment in the formation of diversity, equity, and inclusion (DEI) committees. Yet despite this collective commitment, it is unclear how much has been accomplished to close the gaping inequities in healthcare outcomes that different racial and ethnic groups experience. We propose that investing in civic engagement provides one way to close the racial health gap.

What is health equity?

One challenge to implementing equitable healthcare is understanding what is meant by the term “health equity.” Indeed, health equity is so widely used in current healthcare discussions that it carries many associations. We support the CDC’s definition where health equity covers the body of work needed to ensure every individual attains optimal health. For those who are particularly disadvantaged because of historical and contemporary systemic inequities, implementing health equity may require additional resource allocation to that group to prioritize their needs. Health equity cannot be achieved without addressing the many social determinants of health (SDOH) that drive the worse health outcomes from minoritized racial and ethnic groups. These SDOH include addressing unemployment, inadequate housing, and unsafe neighborhoods, to name a few.

How does civic engagement relate to health equity?

Addressing SDOH falls outside of the scope of work of many health systems. For instance, while we may successfully treat a patient’s HIV or diabetes, we cannot guarantee access to healthful foods or safe shelter that tremendously affect health outcomes. But local municipal boards can work to address these issues. Given the reality that much of health promotion and addressing SDOH falls outside the scope of health centers and clinics, we propose that civic engagement is one mechanism that physicians and healthcare institutions must invest in to achieve health equity. We define civic engagement as encompassing the variety of ways individuals and groups participate in their communities and public life, in service of addressing issues of public concern and/or improving community conditions.

How does civic engagement impact the health of communities?

Civic engagement is an investment in communities because it empowers those who are closest to the issues that negatively impact their health to take on the decision-making capacity that improves health outcomes. To illustrate this, let’s take a look at an example where health outcomes were directly impacted by the decisions of local elected bodies. In Flint Michigan, public officials failed to apply corrosive inhibitors to the water supply. The result was nearly 9,000 predominantly Black children suffering from toxic levels of lead exposure. This failure of public officials to make decisions in the best interest of this population resulted in several elected leaders being tried and convicted for the water crisis that has spanned seven years. In contrast, in To'hajiilee, New Mexico, tribal and state elected officials partnered to negotiate with a private company to improve access to safe water for a rural community. These examples demonstrate what can happen to a community’s health depending on how elected officials engage in health-promoting improvements. Similarly, decisions like which hospitals are closed, or which neighborhoods get access to groceries with fresh fruits and vegetables all arise from advocacy and legislation that local, state, and federal elected officials oversee.

How does civic engagement help physicians?

Physicians care about patients and communities. When SDOH are addressed, patients and communities will have better health outcomes, which could be reflected in improvements in performance measures and quality scores. Additionally, many physicians are personally affected by SDOH, and would directly benefit from the policy decisions that may result from a more civically engaged healthcare and patient population. Lastly, during a time when physicians have record levels of burnout, being civically engaged can help physicians exercise agency through advocacy.

How can physicians support civic engagement?

The connection between civic engagement and health has been demonstrated through various grassroots groups such as Vot-ER and Civic Health Alliance that have created a movement to provide frontline staff with resources and tools to engage patients in voter registration at the time of care.  Hundreds have requested these materials to use with their patients. We’ve also seen physicians testify before local or federal agencies about the impact of gun violence, regressive LGBTQ policies, and reproductive rights restrictions on their patients. All of these are a form of civic engagement in healthcare.

Is civic engagement the same as being involved in politics?

In its ideal form, encouraging civic engagement is apolitical - it simply describes the process of utilizing public institutions to serve the needs of the local community. To be sure, some will see this call for physicians to become more civically engaged as a degrading of medicine’s politically neutral stance. However, we believe the opposite is true. When realities like climate crises, firearms violence, or unaddressed systemic racism are negatively affecting our patients, physicians are called to act. Creating an environment within healthcare where staff and patients actively choose the elected officials who can appropriately address these issues strengthens our commitment to protect the health of our populations.

Furthermore, U.S. law supports healthcare facilities serving as voter registration sites, therefore physicians are within the confines of their legal rights when encouraging patients and their coworkers to get registered to vote. In fact, the Internal Revenue Service and the National Voter Registration Act requires any public office that receives Medicaid dollars to offer non-partisan voter registration booths, a little-known reality that often surprises healthcare leaders who may be reluctant to undertake voter registration for fear of legal repercussions.

What’s the take home?

There is an adage that the best time to plant a tree is 30 years ago, and the next best time is today. The same holds true for physicians becoming civically engaged as a tool to improve patient health, advance health equity, improve population health, and possibly improve their own professional well-being. We may be unsure of where to begin with affecting the change we want to see–we should take comfort that starting with encouraging our peers, patients, and communities to invest in voting and other forms of civic engagement can drive more equitable health.

About the authors: Stella Safo, MD MPH is an HIV Primary care physician based in New York and the Founder of Just Equity for Health (Twitter: @AmmahStarr). Eileen Barrett, MD MPH is Institute for Healthcare Improvement faculty (Twitter: @EileenBarrettNM).