What is health equity? How the idea grew – and why it matters

By Michael Merschel, American Heart Association News

Intpro/iStock via Getty Images
(Intpro/iStock via Getty Images)

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It's an idea as old as modern medicine and as new as the latest medical research. No matter how you look at health equity, the conversation involves contradictions.

But at its core are fundamental questions about illness and health, say experts who have watched the conversation move from the fringes of scholarly debate to the mainstream of 21st century health care.

The term can be abstract, but the facts are not. The richest 1% of Americans have a life expectancy that's at least 10 years higher than those in the poorest 1%. Where a person lives can predict their likelihood of developing heart disease, high blood pressure, diabetes and more.

Health equity seeks to address that. "Health equity means that we achieve health that is as equal as possible, within the constraints of things we can fix," said Dr. Sandro Galea, dean of the School of Public Health at Boston University.

Because explanations of health equity overlap with terms such as inequality and justice, metaphors come in handy.

Galea, who has been studying health equity issues for a quarter century, uses this one: If one person is taller than another, that's an inequality that can't be fixed. However, if medicine is being kept on a high shelf that only tall people can reach, the solution involves equity.

"Health equity is about fixing health gaps that are fixable," he said. "And often, health inequity reflects an injustice, in that we have not paid enough attention to what can be fixed."

Putting it in more concrete terms, Galea said there could be many reasons why one person has higher cholesterol levels than another. But "if your cholesterol is lower than mine because you have access to broccoli, and all I have access to is potato chips, the question becomes, 'Why is that?'"

In one often debated and viral illustration, equity is likened to people attempting to watch a baseball game over a fence; a short person will need a boost that a taller one doesn't.

But such "catchy and compelling brief definitions leave a lot of blanks to be filled in," said Dr. Paula Braveman, founding director of the Center for Health Equity at the University of California, San Francisco.

Braveman, a professor emeritus of family community medicine, has said that if you asked 100 experts for a definition of health equity, you might get 100 substantively different replies. And if you asked her for a definition at different times over the three decades she's been studying the topic, "you might get different answers from me."

These days, her preferred definition comes from a Robert Wood Johnson Foundation report that she helped write: "Health equity means that everyone has a fair and just opportunity to be as healthy as possible. This requires removing obstacles to health such as poverty, discrimination, and their consequences, including powerlessness and lack of access to good jobs with fair pay, quality education and housing, safe environments, and health care."

Such factors are called social determinants of health, another academic term that came of age alongside health equity.

It's also why discussions of health equity often include a history lesson. To cite just one example of how events from nearly a century ago can affect health today, in the 1930s, racist redlining by banks limited where Black Americans could live and whether they could get mortgages. To this day, the neighborhoods they were restricted to are disproportionately exposed to pollution, have less access to healthy food and have higher rates of major cardiovascular problems and heart failure.

Galea offers another metaphor about such problems. Think of a goldfish in a bowl, he said. "Say it exercises, swims around its bowl, eats healthy food, has a good goldfish doctor. But it won't be healthy at all unless you change its water."

The term "health equity" first shows up in medical research in 1966, and ideas around health equity were championed by Dr. Martin Luther King Jr. during that decade.

But Galea said concepts about social justice and health go back at least to the mid-19th century, when German scientist Rudolph Virchow, a pioneer of microbiology, linked a typhus epidemic to social conditions and said the solution was not for more doctors or hospitals but for social changes such as higher wages and universal education.

That makes health equity an old idea, Galea said, but it's seen a resurgence in the past 25 years. "And I think the resurgence of interest has been influenced by a recognition that health should be distributed fairly and evenly."

Braveman first heard the term in the early 1990s, when she was doing work for the World Health Organization. In the U.S., she said, academic interest initially focused on racial gaps in health care. "There was quite an active movement focused on health disparities, and that crowd took up the health equity banner right away, because it was something positive" for people to work toward, she said.

Research interest soared in the 1990s and early 2000s, statistics show. Braveman said that was partly because "the seeds had been sown," and it was an idea whose time had come.

Global politics also helped. Before the collapse of the Soviet Union in the early '90s, "one had to walk on eggshells to talk about these issues," Braveman said. It took the retreat of global communism for public health experts in the U.S. to feel at ease even using the term social justice.

"You really couldn't then," she said. "You could try to talk around it or hint at it using some very concrete illustrations, but you couldn't say 'social justice.'"

Over the next two decades, Braveman has written, the importance of health equity and the social forces that shape health moved "from obscurity and stigma to daylight and respectability."

In 2020, the COVID-19 pandemic brought equity issues into the public consciousness. Death rates from the coronavirus showed huge gaps along racial and ethnic lines, and the nation confronted how someone's job, home and even internet access could be matters of life and death.

"I do think COVID was catalytic," Galea said.

Now, he said, "there's a generation of public health scientists and practitioners who see health equity as being at the very heart of what they do."

Braveman is cautiously hopeful that generation will be able to build on the momentum they've developed. In decades to come, "I would hope that we would move probably slowly but steadily in the direction of greater health equity."

But, she said, progress won't happen without widespread understanding that "there's no health equity without equity." The public must be willing to act on matters of "poverty, child care, housing discrimination, quality education – all those social determinants of health."

That makes health equity a political matter. Which, to her, means that the future of health equity will be determined at the voting booth.

Galea agrees that health equity can't be divorced from politics. But that doesn't mean it has to be divisive, he said, "because I don't think that people of good conscience, regardless of partisan stripe, actually think that health gaps are a good thing, or conscionable."

He looks ahead with an optimism, informed by the past, that comes from embracing contradictions.

Over the past quarter century, he said, "I think there's been enormous recognition of the importance of health inequity." And while discrepancies between Black and white Americans are "unacceptably wide," there has been progress.

For example, between 2000 and 2019, the death rate from cardiovascular causes fell, and the gap between Black and white adults narrowed, according to a study published in the American Heart Association journal Circulation in 2022. And federal data shows that in 1900, the life expectancy gap between Black and white Americans was more than 14 years. In 2021, that gap was down to 5.5 years.

So it can be simultaneously true that "the world is a terrible place, and the world needs to get much better – but the world is a much better place than it's ever been," Galea said. "Those three things are all true."

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