John Rich, a primary care physician and director of the Center for Nonviolence and Social Justice at Drexel University, is a member of The Public Health's panel of experts.

By John A. Rich

During these final days leading up to the election, I find myself more and more aware of the barrage of television advertisements, political commentary and tightening polls. Having consistently voted since I was able, no level of stress or annoyance would make me withdraw from this critical process, despite the annoying background noise. Rather, I have become more of an observer of the phenomenon of pre-election hype.

And as an observer from the perspective of public health, I began to wonder what, if anything, participation in voting might have to do with people's well-being, apart from the critical and contentious debate about the Affordable Care Act.

I was especially interested in this question when following the Pennsylvania voter ID law's circuitous trip through the courts. The law was first upheld by a Philadelphia Commonwealth Court judge and then enjoined, for now, by the same judge after the State Supreme Court instructed him to hold further hearings about whether voter ID cards were widely available and accessible. Politically, I was confused by the seemingly questionable assertions of widespread voter fraud that were used to push the bill forward: What kind of fraud? People voting twice? People from other states coming here to vote? People who had not registered or who were registered in other precincts trying to vote? Undocumented residents risking deportation to vote? Most experts believe that individual voter fraud is not only rare but irrational since it carries a penalty of five years in prison and a $10,000 fine.

What we do know is that voter turnout all across the country is low for what we consider to be a model democracy. Far from people scheming to vote illegally, we have a problem with people checking out of the democratic process altogether. In Pennsylvania, voter turnout has exceeded 60 percent in only two years since 1996, both with presidential elections – 64.5 percent in 2004 and 62.4 percent in 2008.

All of this made the new voter ID law look like a cynical attempt to cut people off from the democratic process, put forth in the name of protecting democracy. As someone whose black ancestors could not vote freely, I could not help but find it reminiscent of the poll taxes and literacy tests of the Jim Crow South, which essentially encoded into law the idea that just being a person was not enough to qualify you to vote.

But putting my public health hat back on, I wondered if there are any potential health consequences of constructing barriers to voting. Without much searching, I came across a paper by Ichiro Kawachi and his colleagues at the Harvard School of Public Health, published in the American Journal of Public Health in 2001. They found that people living in states where there was lower average voter turnout were 62 percent more likely to rate their health as “poor/fair” than those living in places where there was high voter turnout.

They also found that people living in the nine states (West Virginia, Georgia, Virginia, Kentucky, Texas, South Carolina, North Carolina, Tennessee, and Alabama) with the greatest difference in turnout between higher- and lower-income residents and the greatest income inequality were 54 percent more likely to rate their health as fair/poor compared to people living in the 19 most egalitarian states. So it seems that voting, social inequalities, and public health are related.

How could that be? How could the mere act of voting be related to health?

Kawachi and colleagues keyed in two possible explanations. The first is that when fewer poor people vote, there is less public support for programs and policies, such as welfare and job training, that help those with fewer resources. As a result, their health suffers overall. A related explanation is that participation in voting is a form of social capital, a key but sometimes hard-to-define concept in public health.

Social capital represents the degree to which people are actively participating in their communities and how much interpersonal trust and expectations of mutual aid exist. Social capital has been shown in a number of studies to relate to the health of individuals and communities, including mortality. It is a complex idea, to be sure, but it underlines the point: voting as a way of participating in society, and having a sense of control over one's life and destiny, bears on our health. So attempts to hinder, discourage or restrict participation in democracy can only serve to undermine basic health in the long run.

What should we do with this knowledge? Well, whatever we tease out of this somewhat technical research, we should agree that greater, not lesser, voter participation is good for the health of us all. And, whatever our political affiliations, we should go to the polls on Tuesday empowered by evidence that doing so is not only good for the democratic process but may be critical for the future health of our communities and our country.

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Social capital has been shown in a number of studies to relate to the health of individuals and communities, including mortality.