Health equity and health equality. At first glance, these phrases may seem interchangeable. But when you dig deeper, they have very different meanings—and potentially very different outcomes for traditionally underserved populations.
To understand more about these terms and why the difference between them matters, we spoke with Thea James, MD, vice president of Mission at Boston Medical Center and Elena Mendez-Escobar, PhD, MBA, executive director of Strategy at BMC Health System.
HealthCity: How do you explain the difference between 'health equity' and 'health equality'?
Elena Mendez-Escobar, PhD, MBA: When we talk about these terms, it's helpful to imagine a group of people of different heights, ages, and abilities standing behind a tall fence trying to see over it. Equality is giving everyone the same size box to help them see over the fence. Equity is giving each person what they need to see over the fence—for example, a shorter person may need two boxes, whereas a taller person may need no boxes. Our goal is to go beyond this and remove the fence altogether.
Thea James, MD: We also want to establish that, to operationalize equity, you need to first recognize inequity. We're so used to seeing inequity that it appears normal to us, we expect what we are seeing, it is the status quo. So, we don't take the time to look deeper to interrogate what we are seeing. We don't ask the harder questions. Like when we see the fence, we need to ask, "Why is it there? How was it created? Are the boxes given to those people an end solution?"
For example, if someone is hungry in our society, well-meaning people may suggest giving them food stamps. But they don't ask the question, "What are the root causes for why they need the food stamps?" Or "What would it take for them to not need food stamps?" Instead, we fill in the gaps with band-aids as ultimate end solutions versus "eliminating" the gaps, and so nothing ever changes. Ideal end solutions provide access to opportunities that change life-course trajectories, such as employment and careers, financial stability, economic mobility, and building multigenerational wealth.
HC: How does health inequity affect patients at Boston Medical Center and other hospitals?
EME: When we talk about health equity, there are two types of barriers: first are barriers to economic mobility that have disproportionally affected people of color for decades. We know there is a direct link between wealth and health, so not having access to paths for wealth-building contributes to worse health outcomes.
The second type of barriers are related to the fact that systemic discrimination against people of color is pervasive throughout society, and health systems are not immune to it. For example, if we were to prioritize a scarce resource, such as the COVID-19 vaccines, based solely on age, we would be inadvertently excluding some of the neighborhoods most impacted by the pandemic because they tend to have much lower average life expectancy.
We also need to recognize and address a long history where health institutions have not always been worthy of the trust of communities of color.
TJ: It's often said that people of color don't trust the healthcare system because of historical incidents like the Tuskegee study, but I think it's usually more proximal and personal than that. For many people, the mistrust is more about what happened two weeks ago or two months ago when they were engaging with the healthcare system than those historic events they might not even be aware of. The mistrust is happening in real time.
Many of our patients have limited resources. This is a safety-net hospital, so a majority of our patients live at or below the federal poverty line. They are using those limited resources to do things like secure housing, feed their families and keep the lights on. There's nothing left over for prescriptions or healthy, affordable food. Or even money for transportation to get to their medical appointments. They have different priorities. They can't prioritize health because they are prioritizing survival.
HC: How can clinicians and healthcare systems begin to tackle the issue of inequity?
TJ: It's important to acknowledge that our scope of understanding what is causing these barriers is very limited. The limitations are rooted in gaps in medical training and a lack of knowledge and insight into the spectrum of life experiences of populations we serve. The immediate opportunity to fill these gaps is to engage with patients to learn. However, instead of engaging with patients, we often create our own narratives about what we witness and see. Most people only know the life they have grown up in and live. So, when they see lives outside of that, they don't understand and they make assumptions that are sometimes pejorative—or just wrong. Patients sense this and can feel they are being judged, even if it's not intentional.
As we become laser-focused on equity, clinicians will hopefully become more keenly aware of the intersections of inequity, health, and health outcomes. They will be able to recognize inequity when they see it. Clinicians have an opportunity to tackle equity every time they engage with a patient. In the context of their health visit, they can ask the patient what it would take for them to remain stable and to thrive; patients don’t mind this question, it shows genuine interest, warmth, and respect. Honestly, it is literally having an intention to find out what matters most to their patients and honoring that. It is a great start to a partnership that can achieve common goals.
EME: We need to take a deeper look at how to deliver care that truly works for our diverse patient population. Some have the perception that medicine is an exact science, and that there is always a clear "best next step." But often, it's more of a grey area, where there are a number of treatment options, and the right option may depend on what's best for you in your particular situation. Maybe a care plan doesn't work for you because you don't have the time or money to follow the plan. Or maybe a suggested diet includes foods you've never heard of. We hear this from our Black patients all the time. They can't always follow a care plan, not because they don't want to, but because they can't or it does not make sense within their life context. We cannot assume that a care plan is going to be the same for everyone.
HC: What is BMC doing to move closer to a place of health equity?
EME: The first step is to make sure we see the fences that are keeping us from health equity. At BMC, we are rapidly gaining clarity on what those fences are through our new accelerated approach. And we are starting to develop some solutions. But we do not see all the fences or have all the solutions yet. We need to invest in a much, much larger effort. We can't be afraid to ask the explicit questions about race or ethnicity: Is this outcome different by race? If so, why? We can't just keep asking the same generic questions and expect different answers or insights into what is happening.
TJ: BMC began exploring equity in a most unique and unusual manner. We took an approach of putting a mirror in front of ourselves, courageously looking for disparities across the enterprise and interrogating what we found. It's a bold step. But we have to look internally at ourselves to see where we might be inadvertently complicit in helping to create the fences or in not recognizing the fences are there. And, when we identify a fence, we need to dive deeper to see what's causing it. We don't just want to study where health inequities exist, but to dive deeper to see how to fix them, and to fix them expeditiously.
We have intentionality to transform these things using an efficient, faster approach, to see those data change, to make an intervention. It's clear that we have to do something or nothing will ever change.