From the Editor in Chief
Sep 2020

Health of We the People

Audiey C. Kao, MD, PhD
AMA J Ethics. 2020;22(9):E753-756. doi: 10.1001/amajethics.2020.753.


We hold these truths to be self-evident, that all men are created equal,
that they are endowed by their Creator with certain unalienable Rights,
that among these are Life, Liberty and the pursuit of Happiness.­­—
That to secure these rights, Governments are instituted among Men,
deriving their just powers from the consent of the governed.

Declaration of Independence1


As America’s documentary crucible, the Declaration of Independence espouses ideals of equality, humanity, and democracy. The historical truth that its principal drafter and every signer were White men, many of whom owned people as property, is an indelible reminder of where we started, how far we have marched, and how much further we need to go to realize our nation’s founding ideals.

Recently, I had an opportunity to interview members of a bipartisan commission established by the American Academy of Arts and Sciences, a learned society that was founded only a couple years after the Declaration was signed.2 Launched in 2018, the Commission on the Practice of Democratic Citizenship was convened to develop a set of recommendations aimed at reinventing American democracy during an era of distrust in political institutions and cynicism about representative government’s ability to promote the public welfare.3 The sudden arrival of and haphazard response to a novel coronavirus have only served to infect the body politic with greater doubt and pessimism.

While we need those elected to do their jobs and be held accountable as public servants, it is too simple and convenient to deny our personal responsibilities and blame others for the state of our union. In a representative democracy, we the people are the government. As Congressman John Lewis, the late civil rights icon, said in a final, posthumous message to the American people:

Democracy is not a state. It is an act, and each generation must do its part to help build what we called the Beloved Community, a nation and world society at peace with itself…. Ordinary people with extraordinary vision can redeem the soul of America by getting in what I call good trouble, necessary trouble. Voting and participating in the democratic process are key. The vote is the most powerful nonviolent change agent you have in a democratic society.4

In honor of the late Congressman, the United States House of Representatives passed a measure to rename HR 4, initially called the Voting Rights Advancement Act, the John R. Lewis Voting Rights Act.5 The bill is a response to the US Supreme Court’s 2013 decision invalidating a key part of the 1965 Voting Rights Act,6 which eliminated barriers that disenfranchised African Americans, mainly in states across the South. The aforementioned commission has also put forth several recommendations for overcoming barriers to voter registration and actual voting, including same-day registration, voting preregistration for 16- and 17-year-olds, and expanded vote-by-mail options.7 Neither the Lewis bill nor the commission’s recommendations will be enacted before the upcoming November elections. On the contrary, rather than voter registration and ballot access being expanded, there is widespread concern that voting will be dampened by public safety concerns arising from the COVID-19 pandemic.

In response to this pandemic, frontline health care workers have shown up to work even at personal risk to themselves. For some, this commitment to care for those in need has been extended and manifested in new ways. As the pandemic has quarantined many traditional voter registration and get-out-the-vote efforts, health profession students, clinicians, and hospitals have stepped up and taken on this civic responsibility.8,9 Although studies have found a link between civic engagement, such as voting, and health, it’s unclear whether healthy people are just more likely to vote, whether good health is somehow a consequence of voting, or both.10 Regardless of the direction of causality, there are some who think it’s not the job of a physician or nurse to register patients and encourage them to vote. They don’t have the training to do so, and, even if they did, they simply don’t have the time, especially during a pandemic. Bringing politics into the exam room can also be seen by some patients as intrusive, and “differences with the patient or family about political matters [could] interfere with the delivery of professional care.”11 It could be worth noting that a 2007 study found that physicians are less likely to vote than lawyers and the general US population.12

While “bedside” consensus about clinicians’ role in civic engagement is lacking, there is no denying that public policy affects the health and well-being of patients and the public at large. During this pandemic, too many among us have embodied the poor outcomes of acute public policy responses, while not enough of us have borne witness to the disproportionate health impact on disenfranchised communities of chronic public policy failures.13,14,15 How can we afford status quo public policies that undermine social determinants of health? How do we justify trillions of dollars in annual health care expenditures in the United States (where about two-thirds is taxpayer funded16) when public health funding is woefully inadequate? How can a representative democracy survive—let alone thrive—when millions among us cannot earn a decent wage, have affordable housing, live in safe neighborhoods, or get a good education?

If we want to rebuild trust and confidence in representative democracy, those elected need to better reflect their constituencies and be more responsive to their lived concerns. To create a more responsive government, another of the commission’s recommendations is to enlarge the size of the US House of Representatives.17 The last time the House was expanded to its current size of 435 was in 1913.17 Because the US population has grown significantly, the average House district size has increased from 280 000 to nearly 770 000 people per district between 1930 and 2020, and it’s projected to reach nearly 875 000 in 2040.17 In addition to the 31 recommendations issued in a June report, the commission has set a goal of 2026, our nation’s 250th anniversary, to make significant progress on all its recommendations.18 In light of today’s social turmoil and political divisions, this goal seems like a near mission impossible. But what choice is there? We must strive to persevere like those before us who toiled, marched, and died to better our imperfect union.

In the meantime, I call on we the people to register to vote; know our options on how to cast votes; and then exercise our right to vote by November 3. Our nation’s immediate civic and public health might well depend on it.


  1. National Archives. Declaration of Independence: a transcription. Reviewed July 24, 2020. Accessed August 4, 2020.

  2. American Academy of Arts and Sciences. Massachusetts legislature approves academy charter. Accessed August 4, 2020.

  3. Our Common Purpose, American Academy of Arts and Sciences. About the Commission on the Practice of Democratic Citizenship. Accessed August 4, 2020.

  4. Lewis J. Together, you can redeem the soul of our nation. New York Times. July 30, 2020. Accessed August 4, 2020.

  5. Solender A. House approves measure to rename voting rights bill after John Lewis. Forbes. July 27, 2020. Accessed August 4, 2020.

  6. Shelby County v Holder, 570 US 529 (2013).

  7. Our Common Purpose, American Academy of Arts and Sciences. Strategy 2: empower voters. Accessed August 4, 2020.

  8. Stockman F. In era of sickness, doctors prescribe unusual cure: voting. New York Times. July 25, 2020. Updated July 30, 2020. Accessed August 4, 2020.

  9. VotER website. Accessed August 4, 2020.

  10. Nelson C, Sloan J, Chandra A; Rand Corporation. Examining Civic Engagement Links to Health: Findings From the Literature and Implications for a Culture of Health. Published 2019. Accessed August 4, 2020.

  11. American Medical Association. Opinion 2.3.4 Political communications. Code of Medical Ethics. Published November 4, 2016. Accessed August 4, 2020.

  12. Grande D, Asch DA, Armstrong K. Do doctors vote? J Gen Intern Med. 2007;22(5):585-589.

  13. Shear MD, Weiland N, Lipton E, Haberman M, Sanger DE. Inside Trump’s failure: the rush to abandon leadership role on the virus. New York Times. July 18, 2020. Updated July 28, 2020. Accessed August 4, 2020.

  14. Government Accountability Office. COVID-19: opportunities to improve federal response and recovery efforts: report to the Congress. GAO-20-625. Published June 25, 2020. Accessed August 4, 2020.

  15. Association of American Medical Colleges. The way forward on COVID-19: a roadmap to reset the nation’s approach to the pandemic. Published July 2020. Accessed August 4, 2020.

  16. Himmelstein DU, Woolhandler S. The current and projected taxpayer shares of US health costs. Am J Public Health. 2016;106(3):449-452.
  17. Our Common Purpose, American Academy of Arts and Sciences. Enlarge the House of Representatives. Accessed August 4, 2020.

  18. Commission for the Practice of Democratic Citizenship, American Academy of Arts and Sciences. Our common purpose: reinventing American democracy for the 21st century. Published 2020. Accessed August 4, 2020.


AMA J Ethics. 2020;22(9):E753-756.



Conflict of Interest Disclosure

The author(s) had no conflicts of interest to disclose.

The viewpoints expressed in this article are those of the author(s) and do not necessarily reflect the views and policies of the AMA.