Health Equity in the US: Hold the Applause

In a guest post, Courtney McNamara compares policies on health inequalities in the US and UK, and argues that US policies – despite some improvements – have a long way to go before they have any real chance of success.

Achieving equity in health has become an important policy goal for both governments and non-governmental organizations across the world. At the same time, increasing attention is being given to the idea that health is more about the social environments we live in than about what we eat, how active we are, or whether or not we smoke.

Health equity considerations in Europe are often identified on a societal-wide level and attributed to the distributional impacts of public policies. In the US however, ideas of what produces health are less developed, public policies are rarely identified as either causes or solutions to health inequities, and public health professionals are less inclined to stick out their necks politically. Therefore, while it is encouraging that in the US more attention is being given to health equity and the broader determinants of health, these achievements may not always be worth celebrating.

Health Equity and SDOH efforts in Europe and the US

It used to be that American public health professionals differentiated themselves from their European counterparts by framing differences in health as ‘health disparities’.  However, Stateside discussions of health disparities are increasingly being exchanged for standard European considerations of ‘health inequalities’ or ‘health inequities’.

Whereas health disparities or health inequalities highlight crude differences in health, health inequities are often understood as differences in health that are deemed unnecessary, avoidable, and unjust. Considerations of health equity consequently launch us into discussions of ethics, fairness, equality and justice.

That health equity is increasingly being incorporated into American public health discourses likely reflects a larger, global acknowledgement that the health of populations is much more dependent on the distribution of social determinants of health (SDOH),  factors like income, education, and employment, than on individual level behaviors. Because SDOH are socially distributed and exist largely outside the realm of individual lifestyle decisions, differences in health are much more likely to be deemed an inequity.

While it would seem that considerations of health equity would be a welcome addition to any public health discussion, in the US we still find an almost exclusive focus on either the plight of being very poor, or on ethnic and racial inequities in health. Even when shrouded in SDOH lingo, solutions are typically targeted at specific subgroups and continue to emphasize increasing access to healthy choices such as nutritious food options.

Though these are important and necessary discussions to be had, missing is an account of the political sources responsible for the unequal distributions of SDOH. Additionally, few in the US acknowledge what those on the other side of the Atlantic have long professed: systematic differences in health are found between every socioeconomic position, health inequities aren’t just confined to the poor, and solutions need to target economic equality across the whole of society.

Healthy People 2020, for example, sets a 10-year agenda for improving health in the US. However, despite its stated goal of achieving health equity, nowhere in its description of SDOH is attention drawn to the political factors responsible for unequal distributions of resources it’s identified as necessary for health.  Additionally, while the agenda acknowledges that disparities exist outside of racial and ethnic differences, it fails to recognize the role of social hierarchy in implicating all members of society.

Advocating for living wage standards, tax reform, regulation of financial institutions, paid vacations, paid sick leave and paid parental leave, all fall within the realm of public health. Yet calls by UK researchers for a more progressive tax and benefit system are essentially matched by silence in the US.

In a previous post, Ben describes how the Spirit Level, “a book presenting evidence that ‘more equal societies almost always do better’, has become the must-read political book of the year in the UK”. Meanwhile, in the US, public health advocates have been advised to de-politicize SDOH, to avoid words like “justice” and “equality” in discussions of health equity.

So even as SDOH and health equity become more popular topics across America, is celebration warranted? As US efforts continue to compensate for the negative impacts of public policies rather than identify them as the sources of health inequity, perhaps we should hold our applause. For what point is there in discussing health equity at all, if it is not understood within a context that recognizes the very changes necessary for its achievement?