As advocates for health equity—when everyone has a fair opportunity to experience their highest health potential—we must stop talking about eliminating health inequity. Not because inequitable health disparities between groups don’t matter, or because we don’t need to transform systems to achieve equitable outcomes for all. Rather, framing our focus on reducing health disparities obscures the reality that inequities affect us all. Furthermore, the language of “eliminating inequality” centers Whiteness, is mathematically ambiguous, and emphasizes solutions at the individual level.
In this article, I explore these issues and propose an alternative that is more in line with what fairness and justice really means.
Inequalities affect us all
The phrase “eliminating health care disparities” is incompatible with the conceptual and embodied realities of racism. According to American Public Health Association Past President Kamara Jones, MD, MPH, PhD, “Racism is a system of structuring opportunity and assigning value based on the social interpretation of how a person looks (which is what we call ‘race’ ), that it unfairly disadvantages some individuals and communities, unfairly benefits other individuals and communities, and saps the strength of the entire society by wasting human resources. The idea that racism “sucks the strength of an entire society by wasting human resources” means that even the most advantaged groups in society are unable to live up to their full potential within racist and oppressive systems. We are all harmed by structural racism.
As one specific example, economist Lisa Cook, Ph.D., documents how racism stifles patent innovation in the US: between 1870 and 1940, she estimates that society was deprived of 1,100 inventions by black Americans that were never filed. due to mass violence. And I’d say that’s terribly underrated. Imagine all the innovation that has been lost to all of us because of racism. Why invent if you know your intellectual property will not be protected? And how will you have time or energy to “innovate” if you’re trapped in survival mode? That’s lost wealth (and health) for black Americans and for all of us.
Public policy expert Heather McGee’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 like public pools to increased anxiety and poorer mental health. “Racism is bad for white people, too,” McGee says simply.
Racial inequality also costs everyone economically. The National Capital Atlas calculates how much money is lost due to racial income inequality by location in the United States. For example, when racial equality is realized in the Asheville, North Carolina area where I live, the region will reap nearly $1 billion in economic productivity currently lost to racial inequality—without anyone losing economic or social status.
Eliminating inequality centers whiteness
The language of eliminating inequalities also centers Whiteness. When we focus on closing gaps in health outcomes, we really mean: How can we bring “other” groups up to the white (or cisgender, middle class, non-disabled, etc.) standard? Reducing differences between groups implicitly involves “raising” all groups to the white standard. And the centering of Whiteness runs counter to critical race theory, which posits that we must shift our starting point from the majority perspective, which is the usual approach, to that of marginalized groups. We need to center the fields.
This is seen specifically in the objectives for community health priorities. The health outcomes of one community should not always be related to the outcomes of another group by disparity ratios. We can name health care disparities without tying our health priorities to a white standard.
Eliminating the inequality is mathematically ambiguous
Also, we need to stop talking about eliminating health care disparities because the concept is mathematically ambiguous. To eliminate the difference between two values, either the lower number is incremented to reach the higher number, or the higher number is decremented to reach 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 incredible 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 higher for black births compared to white births to 2. 2 times higher. However, this disparity in infant mortality has declined largely because the rate has improved among black communities, but also because infant mortality has worsened slightly among white communities. We are thrilled that the infant mortality rate is falling in black families, and obviously we don’t want white babies to die anymore. Eliminating inequalities does not (necessarily) mean that all groups are healthier.
Why pit communities against each other as if it were a zero-sum game? By articulating our goals in terms of eliminating health disparities, we enable zero-sum thinking. Although it is not true that what supports one group necessarily takes away from another group, the framework for eliminating health disparities can induce thinking about scarcity loss for one group as we fairly invest more in another group.
But the pie is not a fixed size.
Eliminating inequalities emphasizes thinking at the individual level
Finally, if we frame the goal as eliminating health disparities, we are more likely to focus on individual-level solutions (and individual-level blame). Some believe that disparities typically refer to health outcomes, while inequalities typically refer to social determinants, so using “reduction of disparities” in particular may lead us to focus narrowly on changing the behavior of individuals.
Instead of reducing differences 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 needed so that everyone can experience the highest standard of health.
Focusing on benchmarks established by the community
Instead of thinking about eliminating inequality, we could aim to improve outcomes to an ideal but possible standard established by the community. Standards can be set by communities, with intermediate goals based on recognition of communities’ priorities, lived realities and resources. For example, black childbearing people in the United States can choose a maternal mortality ratio (MMR) of no more than 15 deaths per 100,000. Currently, the black MMR in the US is 55.3 deaths per 100,000—similar to overall maternal mortality rates in the countries of Ecuador, the Maldives, Panama, the Seychelles, and Tonga, and three to four times the rate for white births in the United States. There are three or fewer deaths per 100,000 live births in the Netherlands, Norway and New Zealand. Researchers suggest that 60% to 84% of all maternal deaths are preventable. Thus, an MMR of 15 deaths for black childbearing people is approximately the amount that would occur if all preventable deaths were actually prevented in the US.
Efforts to update community-set standards would differ philosophically from efforts to “eliminate health disparities” because they are focused on what is needed to reach the benchmark for a particular group and are focused on absolutes. statistics, not on relative numbers or comparative ratios. Importantly, such a theoretical reformulation cannot resort to individual blame. We must continue to focus on structures and systems that produce these unconscionable outcomes. In practical terms, efforts to operationalize community-based goals may differ from efforts to “reduce health disparities” because we know that a rising tide does not always lift all boats, despite the containment effect (when laws and programs, intended to benefit specific groups, actually benefiting society as a whole). Attempts to enact equity can fail without a community-driven, laser-focused focus on the priorities and needs of each particular group—as defined by them.
Why language matters
So how do we talk about equity in health care without talking about injustices? There is certainly a role for data in scoping problems and understanding where and how we need to act. Yet, as argued here, a narrow focus on eliminating inequalities is insufficient to set more ambitious community-related goals that go beyond simply closing a gap. And when we must use the language of “eliminating inequality” in our health programs, practice, policy, and research, let us at least acknowledge—with students, colleagues, partners, and funders—the problematic nature of this approach.
Why do our words matter? As Bell Hooks said, “Changing the way we think about language and the way we use it necessarily changes the way we know what we know.” Language matters because our words can reflect our heart and shape our minds. Attention to language moves us from a “language just is” — laisse faire, an “it is what it is” mentality — to a “linguistic justice” — a laissez faire of language that humanizes and recognizes the interdependence of us all, for example through human-centered formulation, and less anthropocentric words.
Equity in health care will be experienced (not achieved, as Ryan J. Pettway writes) when we set ambitious but achievable goals for the health of all people and work together to realize those goals.