An Introduction to Health Equity: Legacies, Measurement, and Opportunities for Change
What is Health Equity?
When health equity is achieved, it means that every person has an equal opportunity to be healthy and well, and in turn, that health disparities are eliminated. Opportunities to be healthy and well are often assessed by examining upstream factors that contribute to health, like the Seven Vital Conditions, or the Social Determinants of Health—things like access to humane housing, meaningful work and wealth, and basic needs for health and safety. While achieving health equity is imperative and a goal of many organizations and changemakers working to advance equitable well-being, it’s also a common challenge. This is because inequities are created when barriers exist that prevent individuals and communities from reaching their full potential to be healthy and well, and there are many such barriers in communities across the Nation. Examples of barriers to well-being include poverty, discrimination, and racism, all of which can have consequences like lack of affordable housing, and lack of access to good-paying jobs or high-quality, culturally appropriate health care.
Why Health Equity Matters
Without health equity, vulnerable populations are at risk for disparate access to community resources and conditions that create well-being because of economic, cultural, racial, or physical characteristics. In everything we do to improve our communities, it is important to consider, emphasize, and prioritize health equity; without that, well-meaning efforts and investments are at risk of not only failing to minimize health disparities, but also inadvertently exacerbating them. Achieving health equity is a daunting challenge, but even minor progress towards it can have lasting impact.
Access to healthcare is a clear example where inequities exist: healthcare access is imperative to achieving well-being, yet there are disparities in access related to race and ethnicity, socioeconomic status, location, disability status, and gender identity, among other factors. Implications of lack of access to quality care include delayed care, challenges to getting needed treatment, late and missed diagnoses, and onset of preventable comorbid conditions. These disparities are detrimental to the quality of life and well-being of marginalized populations.
Furthermore, health inequities incur an economic cost, accounting for an estimated $320 billion in annual health care spending. Prioritizing health equity is imperative to achieving well-being for all, and it would reduce healthcare spending while improving health outcomes. Despite this, health disparities persist, in part due to negative conditions that have persisted in the U.S. for years, if not decades. It’s challenging to reverse long-standing conditions due to their pervasive nature and the way they are deeply embedded in society. For example, racism in the U.S. is systemic and has historically prevented people of color from having the same opportunities as their white counterparts for economic, physical, and mental health.
History of Health Equity
Health equity has only become a focal point of public health work in the last two decades or so, though public health practitioners have sought to stratify health outcomes by social class and group since at least the mid-1800s. Early discussions of health equity focused on the social and health impacts of industrialization, including disparities by occupation, class, and living conditions. Though the concept was understood well before, the term “health disparity” did not come into use until the early 1990s and it was not an explicitly-defined term in the United States until the release of Healthy People 2020 in 2010. Equity has been a core principle of health since the founding of the World Health Organization (WHO) in 1948, though at that point, health equity was more aspirational than it was operational.
Racial health disparities, where a significant portion of the focus on health equity now rightly lies, were not studied until 1899, when W.E.B. Du Bois conducted research on social and health problems in the Black community of Philadelphia, in the context of racial segregation. Racism has undoubtedly set the stage for persisting disparities in health to this day. Interpersonal and structural racism have significant impacts on the ability of people of color to survive and thrive. Inequities in upstream factors like the social determinants of health are also driven by systemic racism. One example of these inequities is residential segregation—practices like redlining and mortgage discrimination create racially segregated and disadvantaged neighborhoods where the quality of schools, employment opportunities, and the availability of supermarkets, green spaces, and safe places to play and exercise are all impacted. Stress and trauma stemming from the experience of racism also contribute to poor health outcomes, a phenomenon that can be seen in increased risk of chronic conditions like hypertension in Black Americans, and diabetes in American Indian/Alaska Native populations.
While overall health in the U.S. has improved significantly in the last century (the life expectancy today is drastically improved as compared to 100 years ago), health disparities persist. We see evidence of disparities even in the recent progression of the COVID-19 pandemic, where people of color are disproportionately represented among coronavirus cases, and Black and African American, Hispanic and Latinx, and American Indian and Alaska Native populations have experienced higher rates of hospitalization and death compared to white Americans throughout the pandemic.
Measuring Health Equity
Measuring seemingly intangible concepts like health equity is difficult, but not impossible. There are ways to measure equity as an outcome, and there are also process measures related to equity. Equity as an outcome is achieved when the people with the most need are prioritized and receive the resources they need to thrive. Improved overall population health is not necessarily a sign of increased health equity. Health equity is demonstrated through a decrease in health disparities—worse health outcomes in marginalized groups. Measuring this requires data on community conditions that are broken out by population groups. These data allow changemakers to identify priority populations and develop tailored strategies for improving their health and well-being. Examples include low birth weight stratified by race/ethnicity, or smoking status by highest completed education level.
Equity as a process is achieved when the people most impacted by systemic oppression are engaged in defining and prioritizing issues, developing and implementing solutions, and monitoring progress and accountability. Those who are closest to the problems we face have more knowledge about the nature of the problems and their root causes—often learning from those most affected leads to more effective, efficient, often multi-solving implementation strategies. Measuring this requires tracking the process and documenting who has a seat at the table and how that seat is utilized, as well as speaking with those affected and speaking with people to learn about their lived experience in a community and the barriers to health equity that they face. Often effective strategies are more simple than we think and include things like finding a mental healthcare provider that looks like you. Methods for measuring equity as a process include formalized community conversations and pathways for the public to give feedback on programs and public reporting of the extent to which underrepresented groups are present at all levels of an organization or effort.
Opportunities for Change
One example of a community advancing health equity comes from the Mississippi Delta. The population of this part of the country has been described as “isolated, rural, Black ex-sharecroppers and ex-plantation workers who constituted the vast and silent majority of the Black community, lived in an unceasing, and often losing, struggle against disaster”. Black residents of the region drank contaminated water from drainage ditches, used newspaper as insulation for dilapidated homes, and lacked amenities deemed basic today, like plumbing and electricity. To address these conditions of poor health and poverty, the Delta Health Center (DHC) was created. DHC began operation in 1967, when it became the first rural federally qualified health center in the country. DHC operates under a community-oriented primary care model, meaning in addition to providing medical and dental care, the clinic also develops and implements community development projects that target the social determinants of health, including an agricultural cooperative, transportation services, and educational programs. As a self-described “one-stop shop” for the community, Delta Health Center has demonstrated the ability of one institution to address multiple social determinants. Equity is also central to DHC in both process and outcome. Since its opening, the Delta Health Center has improved the health status of North Bolivar County’s roughly 12,000 Black residents in multiple dimensions. The burden of infectious diseases and chronic illnesses like heart disease, hypertension, and diabetes decreased for Black residents through DHC interventions. Additionally, improvements have been made in the incidence of fetal loss and infant mortality rate for the Black community. Equity as a process has also been prioritized by this effort. For over 40 years, DHC has been owned and operated by the North Bolivar County Health and Civic Improvement Association, the organization of the poor people and communities that the health center was created to serve.
Achieving Health Equity
Achieving increased health equity will require engagement with people in historically marginalized communities that have experienced barriers to well-being, many of whom are advocating for themselves in unprecedented and impactful ways. It will also require allyship and commitment and work from stewards across systems and sectors to decrease barriers to conditions that lead to well-being. Adoption of a well-being framework like the Vital Conditions for Well-Being acknowledges the interconnectedness of our physical health to the community conditions in which we live, and the corresponding disparities in these conditions because of a lack of health equity.
Recognizing and working to limit disparities is a helpful start, even if you don't eliminate them completely. Changemakers can work towards achieving health equity by using data and measurement to identify where disparities exist and engaging the communities that experience them throughout the entire process. Utilizing community health workers and centering compassionate, culturally appropriate care is one way health equity can be operationalized in a healthcare environment. Individuals and organizations working towards health equity, including government agencies and community-based organizations, can also prioritize breaking down public health and healthcare funding silos and increasing interoperability in the health and human services spheres.
Just as health and well-being are dependent on many aspects of life, the pursuit of health equity must be equally multifaceted. The improvement of health care services alone is not enough. To achieve health equity, we must not only decrease barriers to well-being, but also remove the societal circumstances that are a result of these barriers.