The Image of Equity

Many of my childhood thoughts of equity related to women’s rights. I grew up at a time when girls could think about growing up to do the things that men did. However, women’s roles in society had just begun to shift, and there were still very few publicly visible role models—particularly for girls of color. There was a riddle in circulation at the time that went something like this: A man is in a car accident in which his father is fatally injured. The son is taken to the emergency room and operated upon and it is discovered that he is the surgeon’s son. How can this be? Of course, the surgeon was his mother. This was a real brain teaser back in the 1960s and 70s. I sometimes wondered what it would be like if all of us, male and female, fell asleep and suddenly woke up to a world in which half of the heads of state, newscasters, and people on stamps and coins and currency were women. I asked myself, “And what if these differences signified a new world in which the structures of power had shifted?”

Women have made significant strides in education, employment, income, and civic participation over the past 40 years. However, when we consider the health status of women of color and other women experiencing preventable health disparities, there is still work to do.

For example, social determinants of health are conditions in the environments in which people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks. Income is a key social determinant of health; it can make all of the difference in one’s opportunity to be healthy. The wage gap between men and women has narrowed, but it is still substantial. In 1975, women earned 59% of the weekly full-time earnings of men; in 2013, this figure was 82%. However, progress for women has not been the same across racial and ethnic groups, and, since 1975, gaps between the earnings of white women and African American and Hispanic women have actually widened. In 2013, African American women earned 69% and Hispanic women earned 61% of the weekly full-time earnings of non-Hispanic white men, compared to 82% for non-Hispanic white women (and 93% for Asian women).

Similarly, although there have been strides in the health of US women overall, disparities across racial and ethnic groups persist. Heart disease is the leading cause of death for US women. From 2000 to 2010, age-adjusted death rates from heart disease declined for women overall and for women in all racial and ethnic groups considered, but, at the end of this period, glaring gaps by race and ethnicity remained. The rate for non-Hispanic black women was 189.1 deaths per 100,000 population, compared to 142.5 among non-Hispanic white women.

Now an adult, I have become better acquainted with the complexity of the threats to equity faced by women – sometimes through my experiences, sometimes vicariously through the experiences of people that I love, sometimes through hearing accounts of events I could never imagine experiencing, and sometimes through my work as a scientist at CDC. This complexity demands that, even in the face of positive overall trends, we persistently examine the data for pockets of disparity and inequity and examine why these exist. It is not enough to compare men and women or to only make comparisons by racial or ethnic group. Indeed, we need to consider the health status of persons according to their gender, sexual identity, race and ethnicity, disability status, geographic location, income, education, and other dimensions—and our analyses need to account for how these characteristics intersect.

When out to dinner to celebrate the birthday of a dear friend, I was recently reminded of my childhood musings about how the world should look. I turned to the woman next to me, a Native American public health practitioner named Twilla who has lived her life as a champion of diversity, and I asked her for her thoughts on what it is that makes diversity in the public health workforce important. There is plenty of evidence that being treated by a provider who “looks like” the patient is a key factor in the quality of medical care provided to racial and ethnic minority populations. However, there has been insufficient research into whether and how having a public health workforce that “looks like” the US population matters. I wrote the answer that Twilla gave me on a napkin and the napkin is pinned to my bulletin board at work.

“We need to achieve the image of equity. Cultural humility is an important concept but it is still largely unexplored. So we don’t yet know how to prepare the public health workforce to be culturally humble. What we do know is that when people see themselves reflected in the structures of power, they understand the power in themselves, and this is the first step toward equity.”

What is your image and experience of equity?