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Invited Commentary
Obstetrics and Gynecology
July 19, 2019

Political Determinants of Population Health

Author Affiliations
  • 1Children’s Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia
  • 2Zuckerberg San Francisco General Hospital, University of California, San Francisco
JAMA Netw Open. 2019;2(7):e197063. doi:10.1001/jamanetworkopen.2019.7063

There is growing awareness of the association of highly racialized political discourse with health behaviors and, ultimately, health outcomes.1 In this context, the study by Gemmill and colleagues2 finding a significant increase in preterm births among Latina women following the 2016 US presidential election adds novel information to our understanding of the health impact of political events. Using a conservative interrupted time series analysis, they reported that there were 3.2% to 3.6% more preterm infants born to Latina women after the presidential election than the number expected if the election had not occurred. Translated into a more tangible outcome, the results indicate an additional 2337 preterm infants were born in the 9 months after the election, after controlling for seasonal and temporal variation in preterm births as well as trends specific to Latina women. At a population level, the impact of a 3.2% to 3.6% increase in preterm births is not negligible. Putting aside the significant emotional and psychological effects related to the birth of a preterm infant on families, a recent study3 estimated that each preterm infant accrues up to $78 000 in expenditures during their first year of life. Thus, the additional preterm infants born to Latina women following the 2016 election, as documented by Gemmill et al,2 represent a substantial cost for families and society.

Beyond quantification of numbers, an important contribution of this article is the authors’ attempt to define the “critical periods”2 of gestation as the periods when the 2016 election may have been associated with stress for pregnant Latina women. The article identifies a peak in preterm births among women whose conception and second trimester overlapped with the election. This intriguing finding raises the possibility that there are periods of high risk during gestation, which could be related to high levels of acute stress or other physiological insults. While further study is needed, the concept of vulnerable periods could identify novel opportunities for interventions to minimize the likelihood of adverse outcomes.

However, the implications of the study extend beyond preterm birth. More globally, the authors’ findings raise questions about the association between sociopolitical events and population health. Recent work on the “social determinants of health”4 have deepened our understanding of how the health of an individual is shaped by their environment and society. This field of study has highlighted the effects of education, food, housing, and insurance on health outcomes. We have also begun to better understand the ways in which individual and institutional racism and discrimination affect biology and physiology. Furthermore, it is becoming increasingly apparent that such social determinants are associated with health disparities.5 Gemmill and colleagues’ work fits into this broader body of literature but goes one step further by highlighting political determinants of health as a core, but currently understudied, social determinant of health.

In their article, Gemmill et al2 speculate about the potential mechanisms that may underlie the association of this particular political determinant of health with an important perinatal indicator like preterm birth. They refer to existing literature demonstrating an association between immigration policy–related stress and anxiety among Latino individuals and increased cardiometabolic and inflammatory disease, which are known precursors to adverse pregnancy outcomes. In addition, they posit that anti-immigrant rhetoric may be associated with changes in health-promoting behaviors such as accessing prenatal care, which might also create a pathway that culminates in a poor birth outcome like preterm birth. Although these associations have biological plausibility and there is some data to support these claims, the evidence base is meager and further research is very much needed. One potential avenue to pursue is the association of the 2016 election with other important population health outcomes like cardiovascular disease among adults. If changes in birth outcomes were associated with a sociopolitical event such as the 2016 election, it stands to reason that other pediatric and adult outcomes might also have been affected. What is the impact on individuals, the health care system, and overall public health if large subgroups of the population experience increased cardiovascular risk associated with a discrete event? This question has been explored in relation to occurrences such as major earthquakes6 but not with respect to political events, to our knowledge.

To understand the association between sociopolitical events and Latino health will require consideration of the potential differential association of such determinants within the Latino community. Perinatal disparities among Latina women are known to vary by race, nativity, and country of origin.7 Thus, studying outcomes associated with a political determinant of health such as the 2016 election, which was characterized by anti-immigrant rhetoric, slogans, and threats, must consider that pockets of vulnerability might exist within Latino communities. For instance, did recently arrived immigrants or immigrants from Mexico and Central America experience greater changes in preterm birth rates? This is not known. Furthermore, there may be a ripple effect among mixed-status families or immigrants from other regions of the world who may have felt targeted by the presidential campaign and election. Was there a nationwide increase in preterm births among women of Middle Eastern and/or Muslim origins after the election? Again, we do not know. A recent study of births in New York City, New York, by Krieger et al8 reported an increased preterm birth rate among women from the Middle East, North Africa, and other countries included in the highly politicized travel ban that was announced shortly after the 2017 presidential inauguration. However, the numbers of women within these cultural communities were too small to draw firm conclusions. Exploring the association of political determinants with the health of specific national origin subsets within Latino populations and other ethnocultural minorities will likely require nationwide data sets to achieve appropriate statistical power. If we are to find outcome differences within population subgroups that are often aggregated into a single group (such as Asian or Latino populations), national data sets must be created, maintained, and leveraged to address population needs.

Following the US presidential election in 2016, the number of Latino preterm infants increased by 2337 compared with a historical reference period. Such an increase—if truly associated with the election—is not trivial; it might represent nearly $200 million in added expenses to our health care system in a single year. Given the growing recognition of social determinants of health, the study by Gemmill et al2 encourages us to identify and address the political determinants of health. The data they provide are important, but so are the unanswered questions. Clinicians, researchers, and policy makers should continue to prioritize understanding the association between political events, policy changes, and population health.

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Article Information

Published: July 19, 2019. doi:10.1001/jamanetworkopen.2019.7063

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2019 Montoya-Williams D et al. JAMA Network Open.

Corresponding Author: Diana Montoya-Williams, MD, University of Pennsylvania, 3401 Civic Center Blvd, Philadelphia, PA 19104 (montoyawid@email.chop.edu).

Conflict of Interest Disclosures: None reported.

References
1.
Williams  DR, Medlock  MM.  Health effects of dramatic societal events—ramifications of the recent presidential election.  N Engl J Med. 2017;376(23):2295-2299. doi:10.1056/NEJMms1702111PubMedGoogle ScholarCrossref
2.
Gemmill  A, Catalano  R, Casey  JA,  et al.  Association of preterm births among US Latina women with the 2016 presidential election.  JAMA Netw Open. 2019;2(7):e197084. doi:10.1001/jamanetworkopen.2019.7084Google Scholar
3.
Grosse  SD, Waitzman  NJ, Yang  N, Abe  K, Barfield  WD.  Employer-sponsored plan expenditures for infants born preterm.  Pediatrics. 2017;140(4):e20171078. doi:10.1542/peds.2017-1078PubMedGoogle ScholarCrossref
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Braveman  P, Egerter  S, Williams  DR.  The social determinants of health: coming of age.  Annu Rev Public Health. 2011;32:381-398. doi:10.1146/annurev-publhealth-031210-101218PubMedGoogle ScholarCrossref
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Bailey  ZD, Krieger  N, Agénor  M, Graves  J, Linos  N, Bassett  MT.  Structural racism and health inequities in the USA: evidence and interventions.  Lancet. 2017;389(10077):1453-1463. doi:10.1016/S0140-6736(17)30569-XPubMedGoogle ScholarCrossref
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Teng  AM, Blakely  T, Ivory  V, Kingham  S, Cameron  V.  Living in areas with different levels of earthquake damage and association with risk of cardiovascular disease: a cohort-linkage study.  Lancet Planet Health. 2017;1(6):e242-e253. doi:10.1016/S2542-5196(17)30101-8PubMedGoogle ScholarCrossref
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DeSisto  CL, McDonald  JA.  Variation in birth outcomes by mother’s country of birth among Hispanic women in the United States, 2013.  Public Health Rep. 2018;133(3):318-328. doi:10.1177/0033354918765444PubMedGoogle ScholarCrossref
8.
Krieger  N, Huynh  M, Li  W, Waterman  PD, Van Wye  G.  Severe sociopolitical stressors and preterm births in New York City: 1 September 2015 to 31 August 2017.  J Epidemiol Community Health. 2018;72(12):1147-1152. doi:10.1136/jech-2018-211077PubMedGoogle ScholarCrossref
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