What's the Difference Between Equity and Equality?
A frequently cited illustration (shown below) showing the difference between equality and equity is that of three individuals of different heights who are attempting to peer over a fence. In order to treat them equally, they would all be given the same size box to stand on to improve their lines of sight. However, doing so wouldn't necessarily help the shortest person see as well as the tallest person. In order to give equitable treatment, each person would need to be given a box to stand on that would enable a clear view over the fence.
Artist: Angus Maguire
According to the World Health Organization (WHO), equity is "the absence of avoidable or remediable differences among groups of people, whether those groups are defined socially, economically, demographically or geographically." Therefore, as the WHO notes, health inequities involve more than lack of equal access to needed resources to maintain or improve health outcomes. They also refer to difficulty when it comes to "inequalities that infringe on fairness and human rights norms."
The U.S. Centers for Disease Control and Prevention (CDC) refers to health inequities and health disparities interchangeably as "types of unfair health differences closely linked with social, economic or environmental disadvantages that adversely affect groups of people." As such, equity is a process and equality is an outcome of that process. Or, as the Race Matters Institute describes, "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."
Understanding the difference between health equality and health equity is important to public health to ensure that resources are directed appropriately — as well as supporting the ongoing process of meeting people where they are. Inherent to this process is the promotion of diversity in teams and personnel, public health practice, research methods and other related factors. For these reasons, providing the same type and number of resources to all is not enough. In order to reduce the health disparities gap, the underlying issues and individual needs of underserved and vulnerable populations must be effectively addressed.
Equity in Action
There are many successful initiatives in communities around the United States where specific steps have been taken to make approaches to health more equitable. Attempts to achieve equity have involved identifying the individualized needs of specific populations and implementing steps to help meet those needs. Some were created through the CDC's Healthy Communities Program, such as Project Brotherhood — a clinic for black men at Woodlawn Health Center in Chicago. The clinic was formed by a black physician and a nurse-epidemiologist who were interested in better addressing the health needs of black men. Partnering with a black social science researcher, they conducted focus groups with black men to learn about their experiences with the health care system, and met with other black staff at the clinic. As a result of this research, Project Brotherhood employed a number of specific strategies, including:
- Offering free health care, with optional appointments and evening clinic hours to make health care more accessible to black men.
- Providing health seminars and courses specifically for black men.
- Employing a barber who received health education training to perform free haircuts and to be a health advocate for black men that the clinic staff could not reach.
- Providing fatherhood classes to help black men become more effectively involved in the lives of their children.
- Building "a culturally competent workforce able to create a safe, respectful, male-friendly environment and to overcome mistrust in black communities toward the traditional health care system."
- Organizing physician participation in support group discussions to enhance understanding between providers and patients.
According to the organization, positive outcomes were achieved: "In January 1999, Project Brotherhood averaged 4 medical visits and 8 group participants per week. By September 2005, the average grew to 27 medical visits and 35 group participants per week … ." By 2007, Project Brotherhood had provided service to over 13,000 people since the initiative started and created a health services environment designed specifically for black men where they would be respected, heard and empowered, thus helping to reduce the health disparities experienced by this population.
Another organization that has made strides toward increased equity is Poder es Salud (Power for Health), a partnership involving nonprofits, government organizations, local health care providers, and several community and faith-based groups. This partnership was formed to address social determinants of health and reduce health disparities in black and Latino communities in Multnomah County, Oregon, by employing an approach to "increase social capital through durable social networks for the purpose of facilitating the achievement of community goals and health outcomes." This was achieved through three specific strategies:
- Community-based participatory research to support cross-cultural partnerships.
- Popular education, which involves mutual learning and analysis.
- Providing community health workers (CHWs) with specialized training "in leadership, local politics, governance structure, advocacy, community organizing, popular education, and health."
Program effectiveness was reflected in follow-up surveys that showed "significant improvements in social support, self-rated health and mental health among community members that participated in the interventions with Community Health Workers who use popular education."
An additional example of a successful health equity initiative is Project BRAVE: Building and Revitalizing an Anti-Violence Environment. Project BRAVE is a school-based intervention that builds on existing relationships among schools, community members, community-based organizations and local researchers. In doing so, Project BRAVE supports pre-existing opportunities for students to share their experiences with violence and to take part in community change to reduce it. The program's effectiveness was evidenced by an increase in school attendance, which is an important social determinant of community health.
Understanding the difference between equity and equality is a key component in the effort to reduce health disparities among vulnerable populations. The good news is that public health officials can take specific steps to help address this confusion in their own communities — including using educational resources such as the CDC's Defining and Measuring Disparities, Inequities, and Inequalities in the Healthy People Initiative and group exercises such as those suggested by JustHealthAction.org in which teams can work together to differentiate between equity and equality.
We’d like to hear from you! How have you heard these terms used or misused? What issues related to equity have you witnessed in your own community? What is being done to address them and what could be improved? Tell us in the comments or via our Twitter and Facebook channels.
Citation for this content: MPH@GW, the online MPH program from the Milken Institute School of Public Health at the George Washington University