As advocates for health equity—when everyone has a just opportunity to live their highest health potential—we need to stop talking about eliminating health inequities. Not because unjust differences in health across groups don’t matter or because we don’t need to transform systems to produce equitable outcomes for all. Rather, framing our focus on reducing differences in health obscures the reality that inequities affect us all. Furthermore, the language of “eliminating inequities” centers Whiteness, is mathematically ambiguous, and emphasizes individual-level solutions.
In this article, I explore these issues and propose an alternative that is more aligned with what equity and justice truly mean.
Inequities Affect Us All
The phrase “eliminating health inequities” is inconsistent with conceptual and embodied realities of racism. According to American Public Health Association past-president Camara Jones, MD, MPH, PhD, “Racism is a system of structuring opportunity and assigning value based on the social interpretation of how one looks (which is what we call ‘race’), that unfairly disadvantages some individuals and communities, unfairly advantages other individuals and communities, and saps the strength of the whole society through the waste of human resources.” The notion that racism “saps the strength of the whole society through the waste of human resources” means that not even the most advantaged groups in society are able to live up to their full potential within racist and oppressive systems. We are all harmed by structural racism.
As one concrete example, economist Lisa Cook, PhD, documented how racism stifled innovation in patents in the US: Between 1870 and 1940, she estimates that society was deprived of 1,100 inventions from Black Americans that were never filed due to mass violence. And I’d argue that’s woefully underestimated. Imagine all the innovation that has been lost to us all due to racism. Why invent if you know that your intellectual property will not be protected? And how will you have the time or energy to “innovate” if you are trapped in survival mode? That’s lost wealth (and health) to Black Americans and to all of us.
Public policy expert Heather McGhee’s book, The Sum of Us: What Racism Costs Everyone and How We Can Prosper Together, shares additional examples of how racism costs everyone, from the loss of public goods such as community pools to increased anxiety and poorer mental health. “Racism is bad for white people, too,” McGhee says simply.
Racial inequality also costs everyone economically. The National Equity Atlas calculates how much money is lost due to racial inequities in income by location in the United States. For example, when racial equity is realized in the Asheville, North Carolina, area where I live, the region would reap nearly $1 billion dollars in economic productivity that is currently lost due to racial inequity—without anyone losing economic or social status.
Eliminating Inequities Centers Whiteness
The language of eliminating inequities also centers Whiteness. When we are focused on closing gaps in health outcomes, we really mean: How can we bring “other” groups to the White (or cisgender, middle-class, not disabled, and so on) standard? Reducing differences between groups implicitly involves “lifting” all groups to the White standard. And centering Whiteness goes against critical race theory, which posits that we need to shift our starting point from the majority group’s perspective, which is the usual approach, to that of marginalized groups. We need to center the margins.
This shows up concretely in goals for community health priorities. One community’s health outcomes shouldn’t always be yoked to another group’s outcomes through disparity ratios. We can name health inequities without tethering our health priorities to a White standard.
Eliminating Inequities Is Mathematically Ambiguous
Furthermore, we need to stop talking about eliminating health inequities because the concept is mathematically ambiguous. To eliminate a difference between two values, either the lower number rises to meet the higher number, or the higher number drops to meet the lower number. Take the example of the Black-White infant mortality gap where I live in Buncombe County, North Carolina. Through efforts including the amazing work of the community-based doulas of Sistas Caring 4 Sistas, the infant mortality ratio between racial groups has declined in recent years from 3.1 times greater for Black birthing people relative to White birthing people, to 2.2 times greater. However, this infant mortality inequity is closing largely because the rate is improving among Black communities but also because infant mortality is getting a little worse among White communities. We are thrilled that the infant mortality rate is falling for Black birthing families, and we obviously don’t want White babies dying more. Closing inequities doesn’t (necessarily) mean that all groups are healthier.
Why pit communities against one another as if it is a zero-sum game? By framing our goals in terms of closing health inequities, we are activating zero-sum thinking. Even though it’s not true that what supports one group necessarily takes from another group, the framing of eliminating health inequities can trigger a scarcity mindset of loss for one group as we justly invest more in another group.
But the pie is not fixed in size.
Eliminating Inequities Emphasizes Individual-Level Thinking
Finally, if we frame the goal as eliminating health disparities, we’re more likely to focus on individual-level solutions (and individual-level blame). Some consider that disparities usually refer to health outcomes while inequities usually refer to social determinants, so the use of “reducing disparities” in particular may lead us to narrowly focus on changing individuals’ behavior.
Rather than reducing either disparities or inequalities, let’s talk about transforming systems of inequality. The World Health Organization, the Centers for Medicare and Medicaid Services, and others declare that all people have a fundamental right to “the enjoyment of the highest attainable standard of health.” In a world distorted by systems of oppression, the highest attainable standard of health is not the same as the health of the most advantaged group. In such a world—our current world—systems change is required for everyone to experience the highest standard of health.
Focusing On Community-Established Benchmarks
Instead of thinking about closing inequities, we could strive to improve outcomes to an ideal, yet possible, community-established standard. Standards could be defined by communities, with intermediate goals based on acknowledging communities’ priorities, lived realities, and resources. For instance, Black birthing people in the United States may decide on a maternal mortality rate (MMR) standard of no more than 15 deaths per 100,000. Currently, the US Black MMR is 55.3 deaths per 100,000—similar to overall maternal mortality rates in the countries of Ecuador, Maldives, Panama, Seychelles, and Tonga, and three to four times the rate for White birthing people in the US. There were three or fewer deaths per 100,000 live births in the Netherlands, Norway, and New Zealand. Researchers suggest 60 percent to 84 percent of all maternal deaths are preventable. Thus, an MMR of 15 deaths for Black birthing people is approximately the amount that would occur if all preventable deaths were actually prevented in the US.
Efforts to actualize community-established standards would differ philosophically from efforts to “eliminate health inequities” because they are focused on what is needed to reach the benchmark for a particular group, and they are centered on absolute statistics rather than relative numbers or comparative ratios. Importantly, such a theoretical reframing cannot resort to individual blaming. We must continue to focus on structures and systems that produce these unconscionable outcomes. Practically speaking, efforts to operationalize community-established goals may differ from efforts to “reduce health inequities” because we know that a rising tide does not always lift all boats, despite the curb cut effect (when laws and programs designed to benefit specific groups actually benefit all of society). Attempts to enact equity may fall short without a community-driven, laser focus on the priorities and needs of each particular group—as defined by them.
Why Language Matters
So how do we talk about health equity without talking about inequities? There is certainly a role for data in defining the scope of issues and figuring out where and how we need to act. Yet as argued here, narrowly focusing on eliminating inequities falls short of setting more ambitious, community-relevant goals that go beyond simply closing a gap. And, when we must use the language of “eliminating inequities” in our health programs, practice, policy, and research, let’s at least acknowledge—with students, colleagues, partners, and funders—the problematic nature of this approach.
Why do our words matter? As Bell Hooks said, “Shifting how we think about language and how we use it necessarily alters how we know what we know.” Language matters because our words can reflect our heart and shape our mind. Attention to language moves us from a “language just-is” —a laisse faire, “it-is-what-it-is” mentality—to “language justice” —a lasik of language that humanizes and recognizes the interdependence of us all, for instance through person-centered phrasing and less anthropocentric words.
Health equity will be experienced (not achieved, as Ryan J. Petteway wrote) when we set ambitious but attainable goals for the health of all humans and work together to realize those goals.
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October 24, 2022 at 07:07PM
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Language Matters: Why We Need To Stop Talking About Eliminating Health Inequities - healthaffairs.org
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