Original research BMJ Glob Health: first published as 10.1136/bmjgh-2020-004222 on 23 October 2020. Downloaded from Is health politically irrelevant? Experimental evidence during a global pandemic Arnab Acharya,1 John Gerring,2 Aaron Reeves3 To cite: Acharya A, Gerring J, ABSTRACT Key questions Reeves A. Is health politically Objective To investigate how health issues affect voting irrelevant? Experimental behaviour by considering the COVID-19 pandemic, which What is already known? evidence during a global offers a unique opportunity to examine this interplay. pandemic. BMJ Global Health Political leaders in democracies are sensitive to cues Design We employ a survey experiment in which ► 2020;5:e004222. doi:10.1136/ from the electorate and are less likely to implement treatment groups are exposed to key facts about the bmjgh-2020-004222 unpopular policies. pandemic, followed by questions intended to elicit attitudes Electoral accountability is not automatic, however, toward the incumbent party and government responsibility ► Additional material is and it only exists if citizens connect specific policies ► for the pandemic. published online only. To view, to politicians and vote accordingly. Setting The survey was conducted amid the lockdown please visit the journal online ► We know little about how public health attitudes af- period of 15–26 April 2020 in three large democratic (http:// dx. doi. org/ 10. 1136/ fect voting intention or behaviour. bmjgh- 2020- 004222). countries with the common governing language of English: India, the United Kingdom and the United States. Due What are the new findings? to limitations on travel and recruitment, subjects were ► The majority of our respondents believe health is an Received 15 October 2020 recruited through the M-T urk internet platform and the important policy area and that government has some Accepted 16 October 2020 survey was administered entirely online. Respondents responsibility for health. numbered 3648. ► Most of our respondent think their government is to Results Our expectation was that respondents in the blame for the spread of the pandemic. treatment groups would favour, or disfavour, the incumbent ► However, we find that those exposed to key facts and assign blame to government for the pandemic about the pandemic are no more likely to favour, compared with the control group. We observe no such or disfavour, the incumbent nor to assign blame to results. Several reasons may be adduced for this null government for the pandemic compared with an un- finding. One reason could be that public health is not treated control group. viewed as a political issue. However, people do think http://gh.bmj.com/ health is an important policy area (>85% agree) and that What do the new findings imply? government has some responsibility for health (>90% ► It is unclear whether politicians will be punished or agree). Another reason could be that people view public rewarded for their failures or successes in managing health policies through partisan lenses, which means COVID-19 in the next election. that health is largely endogenous, and yet we find little ► Our results suggest that democracies may not im- evidence of polarisation in our data. Alternatively, it could prove health because of electoral accountability as is commonly assumed but perhaps for other reasons. on October 2, 2021 by guest. Protected copyright. be that the global nature of the pandemic inoculated While we are cautious about drawing strong con- politicians from blame and yet a majority of people do think ► clusions from a single experiment, our results also the government is to blame for the spread of the pandemic speak to how political institutions might contribute (~50% agree). toward the sustainable development goals. Conclusions While we cannot precisely determine the © Author(s) (or their mechanisms at work, the null findings contained in this employer(s)) 2020. Re- use study suggest that politicians are unlikely to be punished permitted under CC BY. or rewarded for their failures or successes in managing If public health policies are to succeed they Published by BMJ. COVID-19 in the next election. must receive support from the people they are 1 Independent Researcher, Trial registration Initial research hypotheses centred on designed to help. This is especially true in democ- Washington, DC, UK expected variation between two treatments, as set forth 2University of Texas, Austin, racies, where politicians are subject to periodic in a detailed pre- analysis plan, registered at E- Gap: http:// election and therefore sensitive to cues from the Texas, USA egap.org/ registra tion/6645. Finding no difference between 3Department of Social Policy electorate. However, electoral accountability is the treatments, we decided to focus this paper on the and Intervention, University of not automatic; it exists only if citizens connect Oxford, Oxford, UK treatment/control comparison. Importantly, results that follow the pre-analysis plan strictly are entirely consistent specific policies to politicians and vote accord- Correspondence to with results presented here: null findings obtained ingly. Do issues surrounding public health move Dr Aaron Reeves; throughout. public opinion and do those opinions translate aaron. reeves@ spi. ox. ac. uk into voting behaviour? Acharya A, et al. BMJ Global Health 2020;5:e004222. doi:10.1136/bmjgh-2020-004222 1 BMJ Global Health BMJ Glob Health: first published as 10.1136/bmjgh-2020-004222 on 23 October 2020. Downloaded from We know a fair bit about attitudes toward public health Power analyses suggested a sample size of 1500 in in rich countries, where health systems are expansive each country; that is, 500 for each arm of the exper- and expensive, and especially in the United States, where iment. We were cognisant that the smaller numbers of healthcare is an intensely partisan issue.1–13 We know less Turkers in the UK might preclude reaching a full sample about attitudes toward public health in the developing in that country. However, the more important issue was world, where the topic is rarely studied.14 In neither obtaining sufficient samples in the developed world (for context is the opinion/behaviour nexus well understood. which the UK and USA could be considered together) Although a few studies examine the association between and the developing world (for which India would have public health attitudes and voting behaviour,15 it is diffi- to suffice). cult to infer causality from such observational data. Recruitment took place over several weeks, from 15 The COVID-19 pandemic offers a unique opportunity April to 6 June 2020. The US quota was filled within a to observe the interplay between public opinions about few days, the Indian quota took nearly 2 months, and public health and electoral politics. This pandemic is one the UK quota was not entirely met (n=615). Accordingly, of the worst of the modern era; it is global in scope; it respondents were reached at different points in time is covered intensively by the press; and the role of polit- in India and the UK, offering information about the ical leaders and parties in mitigating or exacerbating the stability of responses. The survey was available in English pandemic is front- and- centre in news reportage. If public for all three countries and in English and Hindi for health matters for popular politics, COVID-19 would India. Survey respondents were compensated through seem to be a perfect storm.16 M- Turk according to rates that account for differences in To assess the question, we launched surveys in the purchasing power parity across the three countries. United States, the United Kingdom and India. Embedded The resulting sample is younger, includes more men, within the surveys is a survey experiment in which we and is more educated than the general populations of prime information about the health and economic the three countries—a common pattern among M- Turk effects of the COVID-19 pandemic. studies.18 The India sample is also more urban and better off than the general population. Additionally, there are some regional imbalances, with London over-represented RESEARCH DESIGN in the UK and southern states over-represented in the The COVID-19 pandemic is global in reach, which Indian sample. Further details are provided in online means mass publics and politicians around the world are supplemental appendix B. confronted with similar challenges. Political responses To ascertain how the COVID-19 pandemic might influ- differ, and exposure to the virus also differs across ence political behaviour we employ a survey experiment countries. However, all citizens share the uncertainty in which key facts about the pandemic are revealed to of knowing that a massive number of deaths—beyond respondents, followed by questions intended to elicit anything experienced over the past century—is possible. attitudes toward the government and potential voting In this general sense, the COVID-19 threat is ubiquitous. choices (this follows a widely employed technique known http://gh.bmj.com/ To gauge public opinion across the world an ideal as the survey experiment19). The first treatment deals research design would incorporate random samples with the possible economic impact of the pandemic drawn from every country at regular intervals. We do and the second concerns its possible health impact. A not have the resources or the logistical wherewithal to filter question ensures that respondents comprehend carry out such a massive undertaking. Nor is it possible in the information that has been presented to them and the midst of this highly contagious pandemic to admin- also serves to reinforce the initial stimulus. Thus, we on October 2, 2021 by guest. Protected copyright. ister surveys person- to-person, which impedes the ability construct an experiment with two treatment groups and to recruit random samples in many countries. For our a control group (which is given no information about the purposes, it is also important to capture opinion in a pandemic).