Last summer in Keene, the eighth biggest city in New Hampshire, Hillary Clinton held an unusual campaign event. She did not talk about the economy. She did not talk about national security. She did not even make her stump speech. Instead, the event featured a panel of local experts on the issue specifically at the top of minds of many in the Granite State: drug abuse.
While this might have seemed odd in the national conversation at the time, it made perfect sense in New Hampshire, which had (and has) been attempting to deal with an epidemic of heroin addiction for the last few years. A WMUR Granite State poll released last summer found that 46 percent of New Hampshire residents said they personally knew someone who has abused heroin in the past five years.
The topic of heroin abuse eventually made its way out of New Hampshire and into national political rhetoric. Former presidential candidates Bernie Sanders and John Kasich also spoke frequently about the epidemic. Kasich, in particular, made it a point to call upon at least one child at his campaign stops, urging them not to do drugs. Perhaps motivated by the issues heightened prominence, on July 13th the United States Senate authorized a diverse set of measures to address opioid addiction. The matter also made its way into this week’s Democratic National Convention, which featured a speech by Pam Livengood, a grandmother from New Hampshire, who has taken custody of her grandson while her daughter and the boy’s father battle their heroin addiction.
This particular crisis was given so much attention and action that one might think it was the only issue of concern to public health officials. Yet in the last year, the Zika virus has arrived in Puerto Rico and the United States.. Revelations from Flint, Michigan revealed that lead has contaminated the town’s drinking water (to this day, this issue has not been resolved). Americans are more obese than ever before, at least in part because 14 percent of them are “food insecure” and cannot access the nutrition they need due to cost, proximity and/or lack of other resources. The list goes on.
To be clear, the heroin epidemic is devastating and certainly worthy of discussion. But it is currently the only public health issue receiving significant, prolonged attention in today’s political conversation. Even Zika, an infectious disease that one might have expected to capture national attention and cause widespread fear and panic like its most recent predecessor Ebola, has generated a fairly tepid response.
In fact, on the campaign trail, discussion of public health beyond opioid addiction and the benefits or ills of Obamacare is virtually non-existent. To her credit, Clinton has made her positive position on emergency funding to fight Zika clear, though she has not made promoting that position a focus of her campaign. Comparatively, Trump has made so little mention of the disease that the first Google result for “Donald Trump Zika Virus” is a satirical piece from the Huffington Post in which Trump promises to build a wall around Manhattan. All that said, neither Clinton nor Donald Trump is actively campaigning to fight Zika, or many of the other issues, like lead poisoning and food insecurity, that threaten our public health.
Given that these are literally and directly tied to the wellbeing of the American citizenry, it is odd, if not irresponsible, for the candidates to ignore public health. Until, of course, one considers three broad realities about this presidential election and the nature of public health itself.
First, voters do not really care that much about public health. This is confirmed in the most recent data from the Gallup poll tracking what American’s view as the “most important problem facing this country today.” Only four percent of respondents said “healthcare,” the most direct proxy for public health offered by the survey. Other potential proxies were equally low on the list of collective priorities. Three percent said they cared most about poverty/hunger/homelessness; three percent said they cared most about reducing crime/violence; one percent was most passionate about gun control; and drugs, abortion, and overpopulation each received a less than .5 percent.
In sum, this means that between only 11 and 12.5 percent of American’s are primarily concerned with public health, compared to the 38 percent of respondents who respond with an economic issue and the between 17 and 19 percent of respondents who respond with an international issue.
It should be noted that a recent Kaiser Family Foundation poll appears to contradict this sentiment. In it, 37 percent of respondents report that “healthcare” and “gun policy,” both important public health issues, are “extremely important” to their vote in the presidential election this year. While that is a lower share than the 46 percent who said terrorism and national security were extremely important, it makes healthcare seem like a somewhat pressing issue on voter’s minds. However, the methodology of that poll, which asked respondents directly about each measured issue, potentially had an observer effect on respondents. By asking respondents to rate issues that they might not have been considering, but that they also wouldn’t necessarily discount, like healthcare, the survey does not prove that voters care about public health. The open-ended Gallup poll is a much more revealing data set, as respondents must report what they are actually thinking about, what they will actually vote on and, in turn, what the candidates will actually talk about.
Second, those who want to garner attention for public health problems face similar challenges to those who want to push issues like climate change to the fore: the costs are all immediate, but the benefits are all in the far future. Take the growing threat of Zika, which Congress has been unable to address through legislation. The $1.9 billion requested by President Barack Obama to fight Zika is supposed to control the spread of the mosquitoes that carry the disease, produce vaccines that can fight it, and develop more accurate testing to find it. The aim of these programs is long-term: preventing Zika from spreading through America. As such, their benefits would not immediately be felt.
Their costs, on the other hand, might. $1.9 billion dollars is by no means an insignificant number, especially for any concerned with the national debt and our federal budget deficit. This cost, in the short term, would add to our deficit now, even if it lead to greater savings, in terms of abated additional costs, in the future. The future is the future; the deficit is being cited in Trump talking points now.
Finally, this election is not about health policy because this election is not really about policy at all. Trump has made it clear that he and his base of supporters do not care about policy in general. “My voters do not care and the public does not care,” he said in an interview with TIME, when asked to give specifics about his policy agenda. He even went so far as to mock Clinton for her focus on crafting policies to address any potential issue that could come up during the campaign. “She’s got people that sit in cubicles writing policy all day,” he said. “Nothing’s ever going to happen. It’s just a waste of paper.”
On this point, he might be right. The aforementioned Kaiser Family Foundation poll, which asked what issues respondents thought were important to their vote in the presidential election, also asked about a candidate's personal characteristics. Forty-six percent of respondents said that these were ‘extremely important’ to their vote, tying with ‘terrorism and national security’ as the top voting consideration above all of the other policy issues. A president’s personality, in other words, is as important to American voters as their most important policy point. Which, to reiterate, is not public health.
Issues of public health, unlike candidates’ personalities, are literally issues of life and death. But unlike plagiarism or polling bumps, they will probably not be brought up between now and November.