Symbolic Policies or stasis in the Public Health Economy: An Analysis of Superficial Change and the Path to Health Equity

Abstract

By Grok under the supervision of Dr. Christopher Williams

The Public Health Economy, as conceptualized by Williams et al., provides a transdisciplinary framework to understand the economic, political, and social interactions driving health inequities. Despite significant policy activity, persistent disparities suggest the presence of symbolic policies—initiatives that create the illusion of progress while preserving systemic inequities. 

Originally termed gattopardismo in Giuseppe Tomasi di Lampedusa's The Leopard, this concept is translated here as "symbolic policy" or stasis to resonate with English-speaking audiences. Symbolic policies, or gattopardismo, are initiatives that create the illusion of addressing health inequities while failing to alter underlying structural barriers. Rooted in the maxim, “If we want things to stay as they are, things will have to change,” these policies prioritize public perception and political expediency over substantive impact [1]. In public health, symbolic policies may involve high-profile campaigns, legislative reforms, or community initiatives that signal commitment to equity but lack enforcement, resources, or focus on root causes. The National Academies report highlights the economic toll of health inequities, costing $1.03 trillion in 2018, underscoring the urgency of distinguishing symbolic from substantive policies to maximize health and economic benefits [2] 

Drawing on the Public Health Liberation (PHL) manuscript, the National Academies report, and a position statement on court decisions, this essay offers a comprehensive analysis of how symbolic policies manifest in the Public Health Economy, particularly in Washington, DC, and proposes transformative strategies to achieve genuine health equity. Through a narrative exploration, it illuminates the systemic barriers perpetuating disparities and underscores the need for structural reform.

Introduction

In Washington, DC, a city rich with resources, health disparities persist, disproportionately affecting minoritized populations. This paradox reflects a broader challenge within the Public Health Economy, a framework that encapsulates the complex interplay of economic, political, and social forces shaping health outcomes (Williams et al., 2022). Despite numerous initiatives, from legislative reforms to community programs, health inequities remain entrenched, suggesting that many changes are superficial. The concept of "gattopardismo," derived from The Leopard and translated here as "symbolic policy," describes initiatives that appear transformative but maintain existing power structures. This essay provides a deep analysis of symbolic policies within the Public Health Economy, using key documents to illustrate their manifestations, limitations, and the urgent need for structural transformation to achieve health equity.

The Public Health Economy: A Transdisciplinary Lens

The Public Health Economy, as defined by Williams et al., is the totality of interactions among agents—healthcare providers, government agencies, community organizations, and industries—that influence community health and well-being (Williams et al., 2022). This framework highlights a state of anarchy, characterized by competition for resources and power, leading to fragmented and inequitable health outcomes. In Washington, DC, for instance, racial and economic disparities persist despite resource abundance, with Black residents facing higher rates of chronic diseases and lower life expectancy (Williams et al., 2022). The Public Health Liberation (PHL) approach seeks to address these disparities by integrating economic, political, and social analyses, drawing from political economy to place health systems within their broader context (Williams et al., 2022). This transdisciplinary lens is critical for understanding how systemic factors reproduce inequities and for identifying intervention points.

Symbolic Policy: Translating Gattopardismo

The term "gattopardismo," rooted in Lampedusa’s novel, encapsulates the strategy of implementing superficial changes to preserve the status quo, famously articulated as, "If we want things to stay as they are, things will have to change". In English, this concept is best captured by "symbolic policy," a term used in policy studies to describe initiatives that prioritize appearance over substance (The era of symbolic policies, 2015). Symbolic policies create the illusion of progress, often generating public support or quelling dissent, while failing to address structural issues. In the Public Health Economy, symbolic policies manifest as reforms that promise health equity but do not dismantle the systemic barriers—such as structural racism, economic inequality, and fragmented governance—that perpetuate disparities.

Characteristics of Symbolic Policies 

Symbolic policies share several key characteristics: 

• Superficial Changes: They implement visible changes that do not address root causes, such as structural racism or economic inequality.

• Lack of Enforcement: Policies may be well-intentioned but lack robust enforcement mechanisms, rendering them ineffective.

• Inadequate Resources: Insufficient funding or resources limit implementation and impact. 

• Failure to Address Structural Issues: They focus on symptoms rather than systemic determinants of health.

• Short-Term Focus: Policies provide temporary benefits without ensuring long-term improvements. 

• Tokenism: Involvement of marginalized groups is superficial, lacking genuine empowerment. 

• Symbolic Capital: Policies may rely on the perceived legitimacy of certain groups or actions to appear effective without substantive change.

• Public Perception: They leverage symbolic meaning to gain public support, often overshadowing limited outcomes 

Framework for Identifying Symbolic Policies 

To systematically identify symbolic policies in the public health economy, the following framework integrates eight areas of inquiry, each accompanied by specific questions and 2 illustrative examples. This framework draws on insights from the PHL manuscript, the National Academies report, court decision analyses, and broader literature on symbolic policies and symbolic interactionism [1, 2, 3].

Policy Intent vs. Impact

• Questions: What is the stated goal of the policy regarding health equity? Has there been a measurable improvement in health outcomes or reduction in inequities?

• Rationale: A policy’s intent must be compared to its actual outcomes to assess whether it delivers on its promises. Discrepancies suggest symbolic intent.

• Example: The Affordable Care Act’s (ACA) Section 1557 aims to prohibit discrimination in healthcare but has not significantly reduced disparities due to underenforcement and legal challenges [2].

Implementation and Enforcement 

• Questions: Is the policy being implemented as intended? Are there mechanisms for enforcement and accountability?

• Rationale: Effective implementation and enforcement are critical for policy success. Weak enforcement often indicates a symbolic policy. 

• Example: Community Health Needs Assessments (CHNAs) require hospitals to address community needs, but limited IRS enforcement and lack of expenditure requirements weaken their impact [2]. 

Resource Allocation

• Questions: Is the policy sufficiently funded? Are resources allocated equitably to address the needs of marginalized communities?

• Rationale: Adequate funding is essential for policy effectiveness. Underfunding or inequitable allocation suggests symbolic intent.

• Example: The Office for Civil Rights (OCR) lacks resources to enforce Section 1557, limiting its ability to address discrimination [2]. 

Addressing Structural Determinants

• Questions: Does the policy tackle social, economic, and environmental determinants of health? Does it challenge existing power structures?

• Rationale: Policies that fail to address structural issues like racism or poverty are likely symbolic, as they do not disrupt the root causes of inequities.

• Example: Washington, DC’s inclusionary zoning policy aims to increase affordable housing but produces few units, failing to address gentrification’s impact on health [1]. 

Community Engagement

• Questions: Are affected communities involved in the policy’s design and implementation? Is there genuine empowerment or just token representation?

• Rationale: Genuine community involvement ensures policies reflect local needs. Tokenism indicates a symbolic approach.

• Example: Some community-based research initiatives offer short-term benefits but lack sustained community involvement, limiting their impact [1].

Sustainability and Long-Term Impact

• Questions: Does the policy provide long-term solutions? Is there a plan for sus taining improvements over time?

• Rationale: Policies focused on short-term gains without long-term strategies are often symbolic. 

• Example: Unconscious bias trainings (UBTs) raise awareness but lack evidence of long-term impact on health outcomes [2].

Transparency and Data Collection

• Questions: Is there transparent reporting on the policy’s progress? Are data collected to monitor health equity indicators?

• Rationale: Transparent data collection is essential for accountability and assessing impact. Lack of data suggests symbolic intent.

• Example: Section 1557 lacks routine data collection on protected characteristics, hindering identification of discriminatory patterns [2].

Symbolic Capital and Perception 

• Questions: How is the policy perceived by the public and affected communities? Does it rely on symbolic capital to appear legitimate?

• Rationale: Policies leveraging symbolic capital (e.g., illness experience, public gestures) may prioritize perception over impact, as seen in patient involvement studies [5]. 

• Example: Public health campaigns during the Covid-19 crisis used symbolic actions to foster trust, but their effectiveness depended on substantive follow-through [4]. 

Manifestations of Symbolic Policies in the Public Health Economy

Symbolic policies are pervasive in the Public Health Economy, as evidenced by legislative, judicial, and local initiatives that fall short of transformative impact.

Legislative Reforms: The Affordable Care Act

The Affordable Care Act (ACA) of 2010 is a hallmark example of a policy with significant symbolic value but limited structural impact (National Academies of Sciences, Engineering, and Medicine, 2024). By expanding health insurance coverage to millions, particularly through Medicaid expansions, the ACA aimed to reduce disparities in access to care. However, its implementation has been uneven, with 10 states opting out of Medicaid expansion, leaving millions of low-income, often minoritized, individuals uninsured (National Academies of Sciences, Engineering, and Medicine, 2024). Moreover, the ACA’s focus on coverage did not adequately address payment models that incentivize treatment over prevention or the lack of diversity in the healthcare workforce, both of which perpetuate inequities (National Academies of Sciences, Engineering, and Medicine, 2024). The National Academies report notes that while the ACA narrowed some disparities, persistent gaps in quality and outcomes highlight its symbolic nature, as it failed to tackle root causes like structural racism and social determinants of health (SDOH) (National Academies of Sciences, Engineering, and Medicine, 2024).

Judicial Decisions: Reinforcing Inequities

Recent U.S. Supreme Court decisions further illustrate symbolic policies by enacting legal changes that maintain or exacerbate health inequities. The Dobbs v. Jackson Women’s Health Organization decision (2022), which overturned Roe v. Wade, eliminated federal abortion protections, disproportionately affecting women of color, with Black maternal mortality rates 2.6 times higher than White women (Public Health Liberation, n.d.). Similarly, Students for Fair Admissions v. Harvard (2023) curtailed affirmative action, limiting educational opportunities for minoritized students, which are critical social determinants of health (Public Health Liberation, n.d.). These rulings, while presented as legal shifts, reinforce systemic barriers, aligning with symbolic policy by failing to advance health equity and instead deepening disparities (Public Health Liberation, n.d.).

Local Initiatives: Inclusionary Zoning in Washington, DC

At the local level, Washington, DC’s inclusionary zoning policy exemplifies symbolic policy. Intended to increase affordable housing, it produced only 1,000 units over a decade, with affordability thresholds often out of reach for the poorest residents (Williams et al., 2022). This initiative, while publicly celebrated, did not address the structural issues of gentrification and economic inequality driving housing insecurity, which directly impact health outcomes (Williams et al., 2022). Such policies create the appearance of addressing SDOH while leaving systemic inequities intact.

Community-Based Research: Short-Term Gains

Some community-based research initiatives, while valuable, also exhibit symbolic characteristics. The PHL manuscript notes that certain studies offer short-lived benefits, such as temporary health interventions, without addressing structural issues like environmental racism or poor housing quality (Williams et al., 2022). These efforts, while engaging communities, often lack the sustained funding or systemic focus needed for lasting change, thus maintaining the status quo (National Academies of Sciences, Engineering, and Medicine, 2024).

Limitations of Symbolic Policies

Symbolic policies fail to address the root causes of health inequities due to several limitations:

• Fragmented Implementation: Policies like the ACA suffer from inconsistent application across states, with nonexpansion states perpetuating coverage gaps (National Academies of Sciences, Engineering, and Medicine, 2024). This fragmentation reflects the anarchic nature of the Public Health Economy, where competing interests hinder coordinated action (Williams et al., 2022).

• Inadequate Enforcement: Laws like Section 1557 of the ACA, which prohibits discrimination in health programs, are underenforced due to resource constraints, limiting their impact on equity (National Academies of Sciences, Engineering, and Medicine, 2024).

• Focus on Symptoms Over Causes: Many initiatives target symptoms (e.g., expanding insurance) rather than structural determinants like racism or economic inequality, which the National Academies report identifies as key drivers of inequities (National Academies of Sciences, Engineering, and Medicine, 2024).

• Lack of Community Empowerment: Symbolic policies often adopt a top-down approach, sidelining community voices critical for addressing local needs (Williams et al., 2022).

These limitations underscore why symbolic policies, despite their activity, fail to transform the Public Health Economy, perpetuating disparities that cost the U.S. $1.03 trillion in 2018 due to excess medical costs and premature deaths (National Academies of Sciences, Engineering, and Medicine, 2024).

Toward Genuine Transformation

To overcome symbolic policies, the Public Health Economy requires a transdisciplinary, community-driven approach, as advocated by PHL and supported by the National Academies. Key strategies include:

• Universal Health Coverage: The National Academies recommend pathways to universal health insurance to eliminate coverage disparities, ensuring equitable access across all populations (National Academies of Sciences, Engineering, and Medicine, 2024).

• Enforcement of Anti-Discrimination Laws: Strengthening enforcement of laws like Section 1557 can address discriminatory practices in healthcare delivery (National Academies of Sciences, Engineering, and Medicine, 2024).

• Increased Research Funding: Only 4.3% of NIH funding from 2012–2023 supported health equity research, highlighting the need for greater investment in studying structural racism and SDOH (National Academies of Sciences, Engineering, and Medicine, 2024).

• Community Engagement: PHL emphasizes community-based participatory research (CBPR) and empowerment to ensure interventions reflect local needs, scaling up promising models like team-based care (Williams et al., 2022; National Academies of Sciences, Engineering, and Medicine, 2024).

• Addressing Judicial Determinants: PHL advocates for integrating judicial impacts into public health strategies, recognizing court decisions as structural determinants that require proactive mitigation (Public Health Liberation, n.d.).

These strategies aim to create a more ordered Public Health Economy, moving beyond the anarchy that enables symbolic policies to thrive.

Case Study: Washington, DC

Washington, DC, serves as a microcosm of the Public Health Economy’s challenges and the prevalence of symbolic policies. Despite its wealth, the city faces significant health disparities, with Black residents experiencing higher rates of chronic diseases and lower life expectancy (Williams et al., 2022). The inclusionary zoning policy, while intended to address housing as a social determinant, produced minimal affordable units, reflecting a symbolic approach that fails to tackle gentrification and economic inequality (Williams et al., 2022). Similarly, community health initiatives often lack the scale or funding to effect systemic change, underscoring the need for PHL’s transdisciplinary approach to integrate local voices and address structural barriers (Williams et al., 2022).

Broader Implications and Future Directions

The persistence of symbolic policies in the Public Health Economy reflects a broader societal challenge: the tension between maintaining power structures and achieving equity. The National Academies report emphasizes that addressing health inequities benefits all populations, not just minoritized groups, with potential economic savings and improved health outcomes (National Academies of Sciences, Engineering, and Medicine, 2024). However, debates persist on implementation, with some arguing for incremental reforms and others, like PHL, advocating for radical reconceptualization (Williams et al., 2022). Future directions should prioritize data collection on race and ethnicity, diversify the health equity research workforce, and foster intersectoral collaborations to address SDOH (National Academies of Sciences, Engineering, and Medicine, 2024). By recognizing symbolic policies and their limitations, stakeholders can work toward a Public Health Economy that delivers equitable health outcomes.

Conclusion

Symbolic policies, as the English translation of gattopardismo, reveal a critical barrier to health equity within the Public Health Economy. Legislative reforms like the ACA, judicial decisions like Dobbs, and local initiatives like inclusionary zoning create the illusion of progress while failing to address structural determinants of health. The PHL framework and National Academies recommendations offer a roadmap for transformation, emphasizing transdisciplinary, community-driven approaches to dismantle systemic barriers. By moving beyond symbolic policies, the Public Health Economy can evolve into a system that ensures equitable health and well-being for all, fulfilling the promise of a healthier, more just society.

Characteristics of Symbolic Policies in the Public Health Economy

• Definition: Policies that appear to address health inequities but maintain existing power structures and disparities.

• Examples: ACA’s uneven implementation, Dobbs decision, inclusionary zoning in Washington, DC, and short-term community research initiatives.

• Limitations: Fragmented implementation, inadequate enforcement, focus on symptoms, and lack of community empowerment.

• Impact: Perpetuates health inequities, costing $1.03 trillion in 2018 due to excess medical costs and premature deaths.

• Solutions: Universal coverage, enforced anti-discrimination laws, increased research funding, and community-driven interventions.

References

• Williams et al., 2022. Public Health Liberation: An Emerging Transdiscipline to Elucidate and Affect the Public Health Economy.

• National Academies of Sciences, Engineering, and Medicine, 2024. Ending Unequal Treatment: Strategies to Achieve Equitable Health Care and Optimal Health for All.

• Public Health Liberation, n.d. Court Decisions Demonstrate Need for Public Health Economy: A Position Statement of Public Health Liberation.

• The era of symbolic policies, 2015. Codename:Act. https://codenameact.org/the-era-of-symbolic-policies/.