By Jonathan Cohen
As right-wing populism fuels a growing crackdown on democracy and civil liberties, lawyers and human rights advocates aren't the only people getting nervous. Public health experts are too. Why? Because studies and anecdotal evidence demonstrate quite clearly that as authoritarianism rises, indicators of health fall.
Donald Trump's election took many in the United States by surprise. But viewed in the context of what's been happening in Europe and other parts of the world, it is just one part of a broader trend. Trump, like ascending conservative leaders and parties in France, Germany, and Italy, among others, has proposed tighter controls on immigration and a rollback of long-standing foreign alliances. With authoritarian politicians and ideas proliferating, the consequences could extend well beyond the realm of policy -- we may get sicker.
Several researchers have found a statistically significant relationship between the level of freedom or democracy in a country and the health of its population. In a 2004 article in the BMJ, Alvaro Franco and his colleagues compared health statistics to the freedom index produced by Freedom House, an independent watchdog organization. They found that free countries -- those that respect political rights and civil liberties -- had higher life expectancy and lower maternal and infant mortality than partially or not free countries.
Franco and his team speculated that free countries have more pressure groups, greater opportunities for empowerment, higher levels of access to information, and government recognition of people's needs -- all of which contribute to good health. Other studies have shown similar connections between democracy and health, including one that showed improved health in post-Communist countries the more they became democratized.
Russia, a country whose leader Trump has praised, is a case in point. The country scored 22 out of 100 in Freedom House's 2016 report, with a freedom score similar to Afghanistan, Iran, and Vietnam. By comparison, the United States scored 90. Average life expectancy in Russia is almost 10 years lower than in the United States. Russia has the largest HIV epidemic in the European Region, and one of the fastest growing HIV epidemics in the world. Although the country is facing a major epidemic of opioid addiction, it prohibits the use of methadone for addiction treatment and even persecutes scientists who promote methadone treatment.
The United States also suffers from a massive opioid epidemic, one that has grown exponentially in recent years. Trump has called it "a tremendous problem." But rather than promoting evidence-based policies like methadone treatment and needle and syringe programs, he has proposed building a wall along the US-Mexico border to stop the inflow of opioids. When challenged on this idea, he compared his wall to the Great Wall of China.
But China may provide the strongest proof of the public health crisis that could await countries that veer down an undemocratic path. During the country's "Great Leap Forward" in the late 1950s, an estimated 45 million people died of starvation and famine. While the Communist Party has offered a variety of explanations, from natural disasters to poor planning, its authoritarian policies may have been the real culprit. The ruling party persecuted people who criticized its agricultural policies, hid information from the public, and overestimated its food supply. As the Nobel Prize-winning economist Amartya Sen has written, "no substantial famine has ever occurred in a democratic country -- no matter how poor."
Effective public health systems depend on respect for evidence and science, a free press, and the rule of law, but voters around the world don't seem to be making that connection. In the United States, public health statistics were a remarkably accurate predictor of voting behavior, according to multiple recent analyses. Counties with high numbers of drug overdose deaths in Ohio and Pennsylvania, two states that were crucial to Trump's victory, also had relatively high numbers of people voting for Trump. The Economist found that counties with high rates of obesity, diabetes, alcohol intake, and lack of exercise -- in other words, poor public health -- accounted for 43 percent of Trump's gains among Republicans compared to Mitt Romney, the Republican candidate for president in 2012.
And Trump won all 16 states with the highest mortality rates, according to a study from the University of Pittsburgh included in STAT's On Call newsletter recently. "These data suggest that Trump voters were expressing dissatisfaction with real problems that included shorter lives and less healthy living conditions," said Dr. Donald S. Burke, dean of the University of Pittsburgh's graduate school of public health.
That's a long way of saying that some of the country's most unhealthy citizens may have unwittingly voted for a man whose policy proposals could make them even sicker.
Jonathan Cohen is director of the Open Society Foundations's Public Health Program, which advances health and human rights by promoting social inclusion, transparency, accountability, and participation in health policy and practice.