Strategies for Achieving Health Equity: Concern about the Whole Plus Concern about the Hole

Abstract

Health equity is a process, assurance of the conditions for optimal health for all people, which requires valuing all individuals and populations equally, recognizing and rectifying historical injustices, and providing resources according to need. At the heart of health equity is concern about the whole of society, not just a single individual or group. Also, at the heart of health equity is concern about the holes in society, about gaps of opportunity and gaps of being valued that are experienced by many. Strategies to achieve health equity that reflect concern about the w(hole) require the examination of a practical roadmap that combines citizenship (WHOLE) with a gap analysis (HOLE). This shorthand of operationalizing health equity as concern about the (w)hole may prove to be useful in generating further strategies for achieving health equity.

Introduction

Health equity is a process, assurance of the conditions for optimal health for all people, which “requires valuing all individuals and populations equally, recognizing and rectifying historical injustices, and providing resources according to need.”1 At the heart of health equity is concern about the whole of society, not just a single individual or group. Also, at the heart of health equity is concern about the holes in society, about gaps of opportunity and gaps of being valued that are experienced by many. We propose a roadmap for achieving health equity that combines citizenship, which we frame as concern about the whole, with a gap analysis, which we frame as concern about the hole.

Citizenship can be distilled as concern about the whole. It is not a narrow credential of belonging to a certain national group or having a certain identity card. It is a spirit of inclusiveness and mindfulness, an understanding that individual well-being depends on the well-being of the whole. It acknowledges our inextricable linkages as part of a larger unit across space and time. It seeks to honor and strengthen those linkages. It is action to benefit the integrity and fitness of the whole.

Gap analysis is concern about the hole. When invited to a decision-making table, or indeed when setting it, the first order of business should involve a look-around to ask, “Who is NOT at this table who has an interest in this proceeding?” Once identified, do not simply try to represent those interests; instead, devise a means to bring the people with the interests to the table. When considering your own work and the work of groups to which you belong, ask, “What is NOT on the agenda?” Then add explicit work toward achieving health equity, including BOTH anti-racism and anti-poverty strategies, to the agendas of all groups to which you belong. Achieving health equity will require concerted and collective action across all sectors and spheres of influence. Look for evidence of two-sided signs, structures which appear “Open” to those who are already inside but are actually “Closed” to those just feet away but outside, on the other side of the sign.2

Identifying the Barriers to Achieving Health Equity

Barriers to achieving health equity have previously been described to include our narrow focus on the individual, our a-historical stance, and our endorsement of the myth of meritocracy. From the individual perspective, there is a self-interest that is narrowly defined combined with a limited sense of interdependence and/or collective efficacy. An a-historical stance is seen by the present as it is disconnected from the past; the distribution of advantages/disadvantages occurs “as-is” without further consideration of those systems and structures that suppressed some and uplifted others. Furthermore, we deny racism exists and promote the value of hard work in a society that is governed under meritocratic rule. These barriers, as well as involving our lack of future orientation and our endorsement of life as a zero-sum game, stand as substantial impediments toward achieving health equity.

The following are some early ideas to spark our thinking and action on achieving health equity in the United States. The first list includes strategies for changing opportunity structures. The second list includes strategies for changing societal valuation.

Strategies for Change: Addressing the WHOLE and the HOLE

Break out of bubbles to experience our common humanity

Become more convinced of our common humanity, more connected to the plights of others, and more motivated to improve conditions for all.

Embrace all children as OUR children

Rather than living in a world where we think about “my” children vs “your” children, we need to understand that all children are OUR children. They are the future for all of us.

Ask “Who are you?” not, “What are you?”

Acknowledge each other’s full humanity without imposing imagined limitations based on “group” memberships and show interest in the stories of others, believe the stories of others, and finally join in the stories of others.

Confront the reality that capitalism profits from unequal valuation

Acknowledge that our economic system of capitalism explicitly profits from unequal valuation.

Understand the importance of history

An understanding of the history of change can be empowering as we seek to make change in our own times.

Challenge the narrow focus on the individual

Extend beyond a very narrow understanding of self-interest to recognize that racism, sexism, and other systems of structured inequity diminish the strength of the whole society through the waste of human resources.

Expose the myth of meritocracy

Clearly name racism, sexism, and other systems of structured inequity which create and maintain the uneven playing field so that we cease to devalue those who have NOT made it in our society by imagining them to be stupid or lazy.

Acknowledge the existence of systems and structures

Shift focus on addressing the physical and social contexts of our lives (the social determinants of health) or the systems of power that create those contexts and differentially shunt different populations into different contexts (the social determinants of equity).

View systems and structures as modifiable

Current structures can be dismantled and replaced with new structures that will serve us better. Just as we can demolish a house or a road that no longer serves us or build a house or a road where none existed before, we can shape our social structures to better serve us all.

Break down barriers to opportunity

Identify and break down existing barriers to opportunity. These prominently include the very different educational opportunities that are available to different segments of our society.

Build bridges to opportunity

Explicitly build bridges to opportunity so that upward mobility becomes a real possibility. For example, strong support for community colleges can make it possible for people to advance by small steps instead of needing to be catapulted by family wealth.

Transform consumers to citizens

To be full citizens, we need to educate ourselves and our children to read widely, to speak more than one language, to be interested in what is going on across town and around the world, and to travel.

Intervene on decision-making processes

Insist on parity, inclusion, and representation in decision-making — an essential manifestation of equal valuation of individuals and communities.

Conclusion

Concern with the whole is about being mindful and providing a better understanding of both context in place (exposures, opportunities, resources, risks) and context in time (personal life course, history of a place, a people, policy, structures). Concern with the hole is about realizing “the absence of” and/or recognizing both who is at the table of decision-making and who is not, what is on the agenda and what is not. It is about becoming attuned to identifying inaction in the face of need, which is a huge part of how institutionalized “isms” manifest and subsequently separate various entities that would yield better outcomes through strong collaboration. This shorthand of operationalizing health equity as a concern about the w(hole) may prove to be useful in generating further action steps towards achieving health equity.