The concept of health equity has gained increased significance in present-day healthcare and public health discourses. This is evident in a wealth of research studies, consultative reports, and international declarations that touch on the issue. Ensuring health equity is a matter of social justice and public health responsibility. It urges achieving equal opportunity to enjoy life, irrespective of the social, political, or economic contexts of individuals. I aim in this essay to discuss health equity and to affirm that health inequality can be addressed effectively by incorporating broader social determinants of health. This line of argumentation is motivated by the moral or amoral status of racial, gender, social, and economic inequalities as limited factors of the distributive scope of healthcare goods and services.
Indicators of the quality of healthcare are not the same for different groups of patients. There is always a gap in healthcare among a unique group of people who experience obstacles to healthcare because they have historically been disempowered on the basis of their race and social status and have previously been discriminated against because of social, economic, and multidimensional aspects. This essay has four rich themes: First, I begin by outlining the significance of promoting health equity within contemporary social and ethical contexts and set out a conceptual foundation in which I engage the reader in a discussion around the ethical case for addressing health inequity, connecting this concept with other ethical, moral, and social endeavors.
Defining Health Equity
Health and healthcare policy discussions frequently reference health and healthcare equity, but do not establish comprehensive definitions of these terms. Health equity does not mean health equality, a single-payer healthcare system, or universal healthcare insurance coverage for all residents. Health equity also does not directly correspond with generous or comprehensive benefits for low-income and underserved residents. Social, public health, and medical professionals, researchers, policymakers, and healthcare administrators must more deliberately use accurate terminology and definitions to avoid perpetuating commonly held understandings that are not evidence-based.
Data from Western countries have shown that although regular use of healthcare services is associated with better physical health outcomes, healthcare only plays a minor role in determining mortality rates. This is because health is multi-factorial. Health is not only negatively influenced by infectious agents, genetics, congenital and neurobiological traits, personal health behaviors and attitudes, but also by public health and healthcare, physical environment, climate change, and health care. A clear definition of health equity is absent in the literature despite its frequent mention. Health equity or inequality can be measured in three dimensions: 1) the access and quality of healthcare services, and the utilization of these services; 2) the social determinants of health that influence health status and/or healthcare access and utilization; and 3) the health status of, risk factors for morbidity and mortality of, or exposure to various diseases by multiple groups or populations. The principle of health equity is that everyone should have the same fair opportunity to make choices that enable them to take the highest level of health or well-being. Health inequity can be defined as the presence of avoidable, unfair, and unjust differences in health or healthcare services between different groups of people, such as among regions, socioeconomic groups, or communities. Being the inevitable result of societal and individual differential perceptions of lack of value—sometimes combined with prejudices, irrational fears, and stereotypes—inequities are generally perceived as unfair or unjust. The ethical principle regarding health disparities is that every effort should be made to reduce, eliminate, or prevent inequities in health and healthcare services the moment they are discovered in a timely, appropriate, and cost-effective manner.
Importance of Health Equity in Healthcare Systems
Health systems worldwide continue to focus on achieving health equity in their efforts. Health equity is important for several reasons. First, it ensures that people with similar health conditions receive similar health services and are thus equally likely to have good health outcomes. Second, inequities lead to an excess or avoidable burden of disease, as resources are not adequately allocated, leading to poor health outcomes and increased burden on services. Due to these reasons, health equity is not only morally right, ensuring that everyone is provided with the best equal chance, but also ensures a healthier society by promoting fair access to care. Poverty or social standing should have no reflection on an individual’s quality and availability of care. Socially disadvantaged populations who do not receive the appropriate care put whole communities at risk of preventable diseases. Racial and ethnic disparities have been linked with lower vaccination rates, increased admission rates, and a higher risk of infectious diseases, posing a burden on the health system as a result. Healthier communities have been shown to be more productive, which is beneficial for society as a whole, and aligns with the social determinants of health.
Health interventions and forms of progress have shown a direct line to health consequences, both positive and negative. It is inconsiderate to permit people to suffer due to a social location or disadvantage that they were born into. Ethical care and equity measures aim to assist specific populations, yet these types of reforms can also interconnect. Multi-level based interventions on more clinically focused health care can support those experiencing poverty. The promotion of universal health care linked with changes in individual professional practices that encourage physicians to recognize the vulnerable could reduce health disparities. There has been a growing interest in the principles and values determining health care reform across the world. On an international level, promoting equity-focused healthcare is not anything new or original. Extensive ranges of resolutions supporting universal health care and primary health care, as well as numerous declarations supporting universal coverage, have been prepared. Equity, fairness, and ethical treatment are central to achieving social justice. Social justice seeks to distribute resources in a way that all individuals and populations have the ability to live a healthy life. This principle of social justice plays a role in theories of distributive justice, where health resources and care should be distributed according to need. Just societies should also strive to create opportunities for the public to maintain their health and to make choices. These community health benefits have an overall effect on social development in the country. It is about ensuring everyone has fair opportunities for safe and healthy living, striving equally to extend the benefits of groups so that living a healthy life is possible for everyone in our community.
Understanding Health Disparities
Health disparities, or preventable differences, in the health status of marginalized communities result from underlying systemic, social, economic, and environmental inequities. It is important to remember that health disparities are distinct from the general term “health equity.” Health disparities describe the gap in health status between disadvantaged communities and the general population, while health equity refers to the goal of delivering equal treatment of all people in terms of health and health care. In the United States, racial and ethnic health disparities remain pervasive. U.S. Black women, for example, are three times more likely to die due to preventable pregnancy-related complications than their white counterparts. Adults living in the poorest areas of Richmond, VA, are also two to three times more likely to be hospitalized or die due to heart disease compared to those from more affluent locales within the same region. These statistics illustrate a rather unpalatable reality—health disparities are still very much a part of U.S. society.
As numerous studies demonstrate, an individual’s ZIP code impacts their risk for substance dependency, chronic stress, depression, and other clinical conditions. Social determinants of health (SDoH), or the nonmedical determinants that influence an individual’s overall health and quality of life—e.g., stable housing, healthful foods, quality education, a sense of connectedness—also play a role in health disparities. Individuals facing poverty or food scarcity, for instance, may be more prone to diabetes, missed developmental milestones, or increased infection during hospital stays due to weaker immune systems. A multitude of social, economic, and healthcare factors can influence a person’s lived experience, and these factors are, in turn, associated with different cultures and subpopulations placing different value on social determinants of health. Ethical healthcare requires that a person be able to access the healthcare they need when they need it, unencumbered by rationing of care, institutional attitudes, ongoing systemic discrimination, underlying poverty and structural inequalities, and personal biases. Healthcare is built on the universality of access principle, justly granting all individuals the same starting resources. Unfortunately, prevailing health disparities illustrate the ways in which this principle is not, in practice, universally upheld. This fact underscores how health disparities are fundamentally unethical. An individual’s likelihood of experiencing a health disparity is not identical across all strata of society. Certain communities, such as those of certain racial or ethnic backgrounds or certain levels of socioeconomic disparity relative to others, experience health disparities at a significantly higher rate in the United States. These prevailing health disparities are both the result and the perpetuator of cycles of poverty with ongoing impacts on the well-being of communities’ youth and future generations.
For example, children who live in poor communities are at a greater likelihood of being born preterm, experiencing poor neurological development, and suffering from traumatic childhood events, all side effects of experiencing poverty. Many children, born and raised in these conditions, fight an uphill battle from conception to generation, meaning poverty and all of its negative health correlates are transferred from one generation to the next. These consequences have cascading intergenerational implications. Experts and activists are engaged in ongoing struggles to identify, track, and expose the existence of health disparities, dynamizing narratives and even inventing new terms to illustrate the lethal effects disparities have on lives from womb to tomb.
Causes of Health Disparities
Certain population groups in the United States are systematically burdened by underlying social and environmental inequalities, which are reflected in reduced age-adjusted health status and life expectancy compared to other populations. These health problems are caused by a complex interplay of several factors, including racial, socioeconomic, environmental, and other social determinants of health. As a result, African American and Hispanic American communities have higher rates of chronic diseases, including cardiovascular disease, obesity, diabetes, and cancer, resulting in greater mortality and disability, and are more likely to have inadequate access to quality health care, employment, and education. People living in poverty are often uninsured or underinsured, making access to appropriate health care even more difficult. Health disparities are also worsened by unhealthy nutrition, physical inactivity, and the use of harmful substances such as tobacco and poor air quality.
The interplay of determinants of health and multiple levels of influence is illustrated in many areas that lead to inequities. The foundations for health disparities are frequently rooted in socioeconomic factors, environmental resources, and physical environments. These are often shaped by public policy, formal and informal social norms and structures, institutional behavior and attitudes, and community factors including race and ethnicity. Thus, the causes of health inequities lie in all aspects of society and all systems. The conditions in which people live are shaped by a distribution of money, power, and resources at various levels. Systemic racism and bias perpetrate the social, economic, and environmental conditions and the systems themselves that negatively affect the physical and mental health of many groups.
Impact of Health Disparities on Society
Level 2: The Impact of Health Disparities
Health disparities compromise health, both individual and on the community level. From a population perspective, disparities elevate public and personal healthcare costs, reduce workplace productivity, negatively impact local economies, and affect social stability, cohesion, and human capital investment. Disparities can also be intergenerational, leading to poor health, economic losses or instability, and decreased productive capacity in the descendants of those originally affected. The socio-economic returns from investing in future health, safety, and educational opportunities include reduced burden of chronic diseases, increased high school and college graduation rates, improved productivity, and greater quality of life. Health disparities lead to two general negative conclusions: they damage the health of those they affect and directly result in increased costs to the public sector and they threaten and strain the social and economic strength of local and national governments, corporations, and communities. There are ethical perspectives for addressing health disparities—such as fairness, justice, and compassion—which form a collective value mantra for how society will handle and confront an ethical, social, and legal health concern. Many studies have convincingly concluded that health disparities negatively affect and harm the macroeconomic health of a society.
Communities and local environments can play a protective role in health. However, socio-economic factors that lead to health disparities can diminish community capacity and neighborhood cohesiveness, and be depleting for the mind, the body, and the spirit and yet all too often go unaddressed or underestimated. Multilevel risk factors contributing to diminished individual and community health are related to stress from personal safety issues, un- or under-employment or under-payment, and health and mental health problems. A community plagued by the multiple burdens of economic hardship, underemployment, substandard housing, poor education, residential segregation, and even high-density alcohol outlets becomes further victimized by disinvestment and declining property values. This creates increased social disorder through illegal drugs, crime, and violence, reinforcing and further increasing unhealthy environments and the powerlessness of neighborhoods and communities to alter their destiny. The resulting political instability and deteriorating social capital lower the quality of life. Addressing health disparities is an excellent societal investment, partly because they increase human capital, making them a driver of economic returns. Tackling health disparities also addresses the enormous economic burden for public and private entities, as addressing these populations’ health problems is a societal one. Many data show that those living in health disparate and/or socio-economically impoverished areas frequently experience the best available care via the public safety net owing to the location of healthcare services in communities and the employment status of these populations. Overall, inaction in addressing health disparities because of cost concerns can lead to larger future costs. Many studies have convincingly concluded that health disparities negatively affect and harm the macroeconomic health of a society.
Strategies for Promoting Health Equity
Policy Interventions
Community-Based Approaches
Technology and Innovation
Challenges and Barriers to Achieving Health Equity
The challenges involved in working toward health equity include not only broad systemic issues, such as structural inequalities and institutional discrimination, but also a number of deeply entrenched attitudes and misguided presumptions about certain groups in society. Power imbalances have led to disparities in income and other social determinants, which in turn lead to inequalities in health. In addition to these structural and societal barriers, political and public resistance to working toward health equity often stems from a poor understanding of the complicated and interconnected interactions taking place in society.
The political and public resistance to working toward health equity is not assisted by a generally poor understanding of the underlying causes and meanings of health inequities. It is important to understand some of the subtle and overt ways in which various barriers may be presented to health equity. These barriers are rarely separate from each other, instead constantly interacting in a mutually reinforcing manner. For instance, inadequate income can lead to inadequate housing or education, which in turn will affect access to healthcare. Furthermore, these barriers can span the complete spectrum from the individual level to broader societal influences; therefore, an effective intervention for this barrier will also span a wide spectrum. The commitment to population and public health and health equity implies addressing a huge number of issues that go far beyond mere medical and technical problems.
Structural Inequalities
Systematic disadvantages that perpetuate poor health and unhappiness among populations are the underlying mechanisms of health inequities. These are systemic and cannot be addressed by telling people to act right or to think positively. Instead, this statement proposes that systematically designed policies for dismantling these unfair structures and processes based on race, sex, and other identities are necessary. The purpose of this breakout session is to define who has the epistemic knowledge of inequality-making regulations and practices in science and the pathways of community health. We use the term “structural” to describe the particular regulations and practices that are embedded in our social, economic, and policy frameworks, such as our systems, boards, and dynamics; in other words, the ways people are treated and resources are divided are embedded in the “way we do business.”
Since people’s health is the end result of economic wealth and social joy, such inequalities are unnecessary and are systematically promoted, making social and health inequities unjust. Racism is a category of structured injustice. Structural inequalities are cemented in unearned authority. Social construction organizations are generated by targeted housing, food, education, shelter, structural function, and related activities. Structural results are therefore visible to vulnerable populations who are marginalized and unable to access the necessary resources, for example, where a building has a record in their client’s hand. Not every person is bad, but there is a system of unearned authority that is reflected in the quality of social relationships by race all around the world. Colonial tyranny, consumption, globalization, and modern technological exchange models have also enforced structural sex and gender discrimination throughout the centuries. Indigenous women are often eroded by rape and humiliation, which perpetuates trauma and is part of the structural issues that have weakened our community. Since we believe that the newest manifestation ignores a history of dissatisfaction, we cannot view these instances as potential “events.” Peers who watched me race differently were killed last month or were shot at. These injuries are not improbable, but are always more predictable in a context of organized ongoing injustice.
Access to Care
A central aspect of health equity is how services are delivered and who can access those services. National healthcare shifts and breaks have emphasized this access, raising it to a national conversation topic. This is important; without access to care, we cannot ever achieve health equity. Enormous disparities in access to care exist. Some, like the rural-urban divide, the severe shortage of healthcare workers, and the few services available, are rooted in geography and difficult to address. Others, such as the cost of care that individuals can afford, insurance coverage that provides some guarantee of financial protections, and systemic barriers in care design and delivery that place an excessive burden on the patient, can be addressed.
In a sense, offering information on the numbers of people who have inadequate access to care represents a missed opportunity to include educational technology with a large need and deliver health equity-enhancing information. Ensuring access to care gets the science-based preventive, acute, and long-term services needed to promote and sustain good health, prevent illness and injury, have the opportunity to identify and address illness early to improve outcomes, and receive care promoting recovery and maintenance of well-being. Systems play an equally central but different role. Systems, like increases in providers or training programs, telehealth, workforce improvement, and retention strategies rural communities need, hospitals and health services designed to match disease prevalence, directly affect the ability to get health care. Systems also do this by impacting insurance and cost of care because those barriers lead to an effect on whether and when a person can seek needed services. By making the illness and its sequelae difficult to prevent and manage, systems also play an indirect role. Care design that is not patient-focused and places an undue burden on the affected individual wastes resources, lowers quality, drives up populations’ poor health, and disproportionately harms vulnerable populations. The most effective and most ethical route to health promotion, disease prevention, patient-centered healing, and treatment design is to ensure that the populations served face no or few barriers in the ability to get care.
Social Determinants of Health
As much as the size of a bank account or the rate of heartbeats may be a person’s health destiny, social determinants of health also play a large part. Social determinants are the conditions in which we are born, grow, live, work, and age; they shape the lives, statuses, and health of all people in the developed world by deciding how fair and inclusive their societies are. A person’s social status in a given society is a more significant determinant of health and health outcomes than their genetic makeup. The largest barriers to achieving health equity are the adverse social determinants and a cultural environment that limits individuals from actually accessing care and maximizes the influence of artificial health disparity. All these factors combine and affect the health that people experience.
Many social determinants of health disparity have been highlighted by social justice organizations and scholars growing up in communities, particularly in African cities. Education is one of the most prominent social determinants of health. Individuals who belong to families with a higher socioeconomic status than their peers in high school have a higher education rate and report better health measures than their region’s inhabitants with less education. Among people with the lowest incomes, the healthiest foods are often unavailable. In the inner city and rural areas, citizens live in deprived neighborhoods with limited access to food outlets and cannot get enough or make nutritious meals. The social, environmental, and work conditions differ between New York City and Albany. Addressing Albany’s poor neighborhood health effects is just as important as trying to improve the inner cities of New York City. Social conditions can be closely associated with inequalities. Active changes to the structure are important, but long-term institutional alterations have a much greater probability of success.
Health disparities are a direct result of the socioeconomic conditions in which individuals live, learn, work, and play. This understanding of the social determinants of health represents the foundation of systems thinking and proof that if we want to fix our healthcare system, we must address health disparities. We must also acknowledge that the concept of health equity depends on a full understanding of systemic structures and societal dynamics, and that the eradication of one structure may not be sufficient to transform the nature and management of healthcare in the U.S. For these reasons, the process of promoting health equity must address the need for new organizational structures, a realignment of systems, and societal dynamics, all of which must synchronize to lead toward a multifaceted approach to fostering health equity. The findings not only validate a number of successful strategies for advancing health equity but also help identify some challenges and recommendations for those looking to further integrate health equity into healthcare. Promising strategies included a doctrine focused on medical effectiveness, policy development, organizational-level support, and public awareness. Some recommendations for integrating health equity into care included the need for attention to a political and ethical argument, engagement of multiple stakeholders, the power of advocacy, funding from multiple sources, and adequate evaluation of outcomes and impacts. The contributors also highlighted the potential of expanding access to social policy and introducing programs that encourage social inclusion. Stakeholders emphasized the significance of social determinants, continued research on these topics, and a recommendation for a conceptual framework to expand further decision-making to include factors beyond the purview of the healthcare system. Ethics and ethical arguments are grounded in the importance of making right or good decisions for others. The moral and ethical imperative for a focus on health equity in healthcare policy and practice has to be kept at the forefront of the promotion of health equity in healthcare. Moreover, the attainment of health equity will require a significant reorganization of U.S. social policy. Healthcare stakeholders must therefore engage with social determinants beyond their traditional scope of practice to work with multiple departments and policy sectors as stakeholders to promote a broader effort to build an inclusive society. Given the interconnected nature of the multiple determinants of equity and health, commitments to systems approaches are vital to the development of effective ways of addressing health disparities. Ongoing research to evaluate multisectoral action, responsible investment direction, and partnership results related to health equity are required to continuously expand our collective knowledge to advocate for improvements. Ethical and interest-based stakeholders include healthcare delivery systems and insurers, alongside managed care organizations and investors, and policymakers.
Summary of Key Points
Several conclusions can be drawn from this commentary. Although definitively measuring health equity is elusive, health disparities are disproportionately poor health indicators experienced by certain groups. Eliminating these disparities and achieving health equity is not only fundamentally important for large groups of people, but it speaks to who we are as a society. Health disparities are not random or accidental but are rather systemic of society. While there are many ways to close health gaps, achieving health equity is possible. The challenges and obstacles to meaningful progress have been outlined herein, providing context for what it will take to reach our goal. Disparities are persisting due to differences in power, prestige, and resources, and the social determinants of health play enormous roles in determining the conditions in which adults and children are born, raised, live, work, play, worship, and age.
Practical and important strategies are available to address the root causes of health disparities in the short and long terms. Some strategies focus on preventing disparities before they happen and closing them as quickly as possible. Area-based initiatives and interventions are community-based approaches that seek to decrease health disparities through systemic interventions. Finally, innovations in healthcare such as telemedicine and electronic health records can improve access and delivery, and are notably applicable in rural areas where access to care is especially challenging. Understanding disparities largely involves problems of a historical, social, and contextual nature that cannot be—nor should be—weathered by the movement alone. One of the biggest misconceptions—and a barrier to achieving progress—towards health equity is the idea that society has already sufficiently “leveled the playing field”—a claim that requires some of the most egregious ignorance and apathy of social, historical, and structural inequities in human history.
Call to Action for Building a Fair and Inclusive Healthcare System
Across nations, there exists a mandate for a healthcare system that is fair and inclusive for all populations. The responsibility for addressing health disparities is a shared commitment among federal officials, state and local agencies, local policymakers, healthcare providers, and non-profits and research organizations. We call on stakeholders to join us in a call to action. We invite you to: · Advocate for the inclusion of equity within the identified health priorities in your geographic area. · Urge local hospitals to leverage cutting-edge medicine to showcase their commitment to equitable care. · Collaborate with researchers and clinical providers to innovate programs designed to change healthcare professionals’ behaviors. · Partner with healthcare organizations and foundations to develop more accountability for public and private policymakers and their community collaborators. · Publicize recent studies that indicate that diverse teams are more successful in making significant improvements in quality across various performance measures. · Advocate for the commitment of reimbursement, payment, and better incentives for providers to achieve equity. · In every step of your work, choose to either be a champion of equity or, at the very least, to do no harm. In a world where we seem unable to reach agreement on much of anything, let’s at least agree on some sensible strategies that can move our nation toward achieving a fair and inclusive healthcare system as a reality for us now and for our children and future generations. For some, our call to action may seem “too much to ask,” and traditionalists may retrench, refusing to coalesce with stakeholders not traditionally at these tables. We believe, proudly and with a voice of humble and fervent conviction, that communities committed to achieving a fair and inclusive healthcare system will inspire us all, one day. We have already seen progress and change. We know that we can win if we are united in our pursuit of a fair and inclusive system. We also know something that shouldn’t need to be said, but we reaffirm here today that it is people, and not the market, funders, or outcomes—whether high or low—that matter most in this world and in our own little universes. We believe, and we hope you will consider our affirmative belief that it is possible. And it is possible if we support and engage one another.
