According to the Merriam-Webster Dictionary (20118), equitable means “having or exhibiting equity or dealing fairly and equally with all concerned” (2018). In an equitable society everyone would have equal access to goods and services regardless of socio-economic status, gender, race, and the alike. When we look at equity from a health lens, that means that everyone has the opportunity to achieve their highest level of health (Benjamin, 2018). Now, in an ideal world, that would be great, however, since we do not live in one, there is ample opportunity and need to achieve health equity.
Health equity is “the principle underlying commitment to reduce – and, ultimately, eliminate disparities in health and in its determinants, including social determinants” (Braveman, 2014, p. 6). Achieving health equity means ensuring health for everyone, especially populations at great risk for poor health based on socio-economic status. Achieving health equity is growing in demand and necessity to truly improve population health. A growing body of evidence links differences in health among populations to social, economic, and environmental factors.
One way to measure progress towards health equity is health disparities. Healthy People 2020 define health disparities as a “particular type of health difference that is closely linked economic, social, or environmental disadvantage.” These disparities adversely affect a population who has experienced greater social or economic barriers to health based on their race, religion, socio-economic status, gender, age, sexual orientation, physical disability, or even geographic location.
Let’s consider two families who live in a rural community, one of them is of high income and the other low income. Both families seek medical care as needed from a health care provider who visits a local clinic two times a week, with the high-income family who has health insurance through an employer and the low-income family who must pay out of pocket. However, when health care needs require specialty care in another city, such as a dermatologist or oncologist, the high-income family likely has the means to access that care while the low-income family does not have the opportunity to access care due to income and transportation barriers. Thus, reducing the opportunity to live the highest level of health.
If you are paying attention lately, health equity is the focus of many conferences nationwide, as well as research and public health practice. Powerhouse public health organizations understand the enormity and necessity to achieve health equity and creating a culture of health where we live, work, learn, and play, regardless socio-economics. Specifically, the American Public Health Association identifies creating health equity as one of its “guiding priorities and core values”, and the Robert Wood Johnson Foundation mission is “to improve the health and health care of all Americans”, creating a culture of health. While achieving health equity is a guiding priority for national organization, it is also a focus for many federal, regional, state, and local entities. Federal funding agencies are taking stock of the need to address health disparities at the local level to improve health outcomes. Local agencies are also taking notice and shifting efforts towards achieving health equity by reducing socio-economic gaps that exist among advantaged and disadvantaged populations, including educational opportunities or access to quality and affordable housing.
The reality is that differences to exist between rural, urban, and tribal communities. Research shows that rural populations are decreasing in size and people are moving to urban areas. Rural America face inequities that results in poor health outcomes and higher chronic disease rates when compared to urban communities, due in part to access to care, geographic isolation, low employment and income. In addition, rural residents who live on farms, ranches, reservations, and frontiers often are forced to travel long distance to access health services, which means taking time off work throughout the care process. Many tribal communities are in rural America and affected by similar factors. However, American Indian and Alaska Native people have also historically experienced lower health status compared to other Americans, including lower life expectancy, higher disease rates. Inadequate education, disproportionate poverty, and cultural differences are just some of the quality of life issues that are rooted in economic adversity and poor social conditions that affect tribal communities (Indian Health Service, 2018). Conversely, even though urban areas are growing and assumed to have available resources to support resident to live the highest health possible, inequities are present in urban settings. Food deserts, food insecurity, and access to goods and services due to income are just some of the factors continue to affect populations in urban areas.
Is it also important to discuss the role that racism and discrimination play in our communities. According to the APHA Executive Director, Georges Benjamin, "It is simply impossible to talk about the roles that racism and discrimination play in the health of our communities without taking a hard look inward..." Achieving health equity means naming racism and discrimination as a force in determining how social determinants, such as employment, housing, healthcare food access, and education, are distributed (Benjamin, 2018).
So how is health equity achieved? Recently, I had the opportunity to moderate a panel of public health experts whose focus expands urban, rural, and tribal communities. While there are unique health differences that affect these communities, one common theme across them to achieve health equity is collaboration. Collaboration with a diverse group of partners and sectors who can come together to address the social, economic, and environmental factors that influence health and create this divide. If a child does not have access to food, how can we expect them to succeed in school when they are hungry. This is an opportunity where the education and community and even business sectors can intersect. In the words of the panelists, “there is always opportunity to collaborate, it just may mean looking at it from a different lens.” According to the American Public Health Association, we achieve health equity by valuing all people equally – optimizing conditions in which people live, work, learn and play. Moreover, investment in communities and public health, not less, is a key strategy to achieve health equity, including investment in rural communities.
So, how can society improve the health of populations and achieve health equity if we do not recognize the factors causing those inequities?
American Public Health Association. (2018). Health Equity. Retrieved from https://www.apha.org/topics-and-issues/health-equity
Benjamin, G. (2015, May 19). Health equity and social justice: a health improvement tool. Grantmakers in Health. Retrieved from https://www.apha.org/-/media/files/pdf/topics/equity/health_equity_social_justice_apha_may_2015.ashx?la=en&hash=1AB844B23465836A5ECAEEFA12FAD0805C16CEC2
Braveman, P. (2014). What are health disparities and health equity? We need to be clear. Public Health Reports, 129(2), 5-8
Indian Health Service. (2018, April). Disparities. Retrieved from https://www.ihs.gov/newsroom/factsheets/disparities/?mobileFormat=0
Warshaw, R. (2017, October 31). Health disparities affect million in rural U.S. communities. Association of American Medical Colleges News. Retrieved from https://news.aamc.org/patient-care/article/health-disparities-affect-millions-rural-us-commun/