By Karen Krigger, MD

Healthcare quality is often quantifiably measured by health outcomes. Multiple studies support consensus the USA spends more per person than any comparable nation with the worse healthcare outcomes, including life span. The accounting of this discrepancy among comparable nations can be attributable to unrecognized health inequalities driven by recognized, but unattended, social inequities. These terms represent the realm of public health.

Equality vs. Equity

Equality means each individual or group of people is given the same resources or opportunities.  Considering health equality, it would mean everyone, given the same resources or opportunities, would be as healthy, equally, as the next person.

But we know that equal resources and opportunities given to each person does not insure health equality. Hence, we have the concept of health equity. Equity recognizes each person has different circumstances. In the context of health equity, each person is given the exact supplies, means, and opportunities needed to reach the same health outcome.

Equity is the absence or avoidable or remediable differences among groups of people, whether those groups are defined socially, economically, demographically, or geographically. Thus, health inequities are more than lack of equal access to needed resources to maintain or improve health outcomes.

Redlining

Health inequities, also, encompass those difficulties that infringe on fairness and human rights. An example of these difficulties can be found in redlining. Redlining was instituted in 1933 by the US government with the creation of the Homeowner’s Loan Corporation (HOLC) to bolster national housing market and homeownership opportunities. The HOLC created residential securities maps, i.e., redlining maps, to guide investment in US cities. Black, immigrant, and low-income neighborhoods were often given low grades denying them access to mortgage insurance or credit.

In these neighborhoods you see higher rates of pulmonary and cardiac disease, cancer, and other health conditions. It is from these neighborhoods you see a higher infectivity and mortality rate from COVID-19 as their dwellers are less healthy.  

Reverse Redlining

There is the concept of reverse redlining affecting the economies of these neighborhoods. Reverse redlining manifests by offering services for low-income residents at higher prices and higher interest rates. Car insurance premiums, for example, are determined by zip codes creating pricing discrepancies irrespective of credit history in these redlined communities.  

Community Equality

An example of community equality would be the following: A city budgets closes all the swimming pools in the county due to budget cuts. Community equity would be an investigation of the usage by numbers and hours, the ages and numbers of the population affected, and the potential for youth related offenses due to lack of neighborhood youth related services. Reviewing the impact of the closures with these metrics may open pools in areas most needed and not available within the family’s economic structure, i.e. There are no private neighborhood pools.  

The Centers for Disease Control defines health equity as when everyone has the opportunity to be as healthy as possible. Health equity will be a process we actively engage as a nation, while health equality will be the outcome of that process.

Paula Dressel of Race Matters Institute succinctly states our needed actions – “The route to achieving equity will not be accomplished through treating everyone equally. It will be achieved by treating everyone equitably, or justly according to their circumstances.”

Eventually, the goal of justice, and consequently, improved health outcomes, will be achieved when we view inequalities through the lens of inequities. The view through such a lens will require a recognition within our subconscious minds of equity, equality and justice.

To begin your journey, consider implicit bias testing. Implicit bias results from the tendency to process information based on unconscious associations and feeling, even when these are contrary to one’s conscious or declared beliefs. You can take a self-assessment at https://implicit.harvard.edu/implicit/takeatest.html.

-Karen Krigger, MD, MEd, FAAFP, AAHIVM(S) is the Director of Health Equity, Health Sciences Center, University of Louisville.