In their fight to get “critical race theory” (CRT) (or what they call CRT) banned from schools, James Lindsay and Christopher Rufo have twisted the terms “equity” and “equality” so they can better “beat” their opponents. But, unfortunately for them, there is a distinction between the two and the distinction between the two matters for issues of social justice. Although they don’t really understand the concepts they attempt to discuss, their readings into CRT/social justice have been repeated as if they have any meaning at all. By attempting to change the definition of equity, they are attempting to shift the discussion to what equity IS NOT, thereby attempting to side-step social justice issues. (Which is actually their goal.) This article will discuss what equity and equality are and aren’t, and how we can achieve equity not only in health but for all facets of our society.
What equity is; what equity isn’t
Lindsay, for example, makes the claim that “equity means “adjusting the shares in order to make citizens A and B equal” which would make “equity…something like a kind of “social communism”“. Lindsay’s confusion here will become apparent by the end of this article, as he is clearly strawmanning what “equity” means.
Chris Rufo (professional charlatan, like Lindsay), in his article Critical Race Fragility claims that:
critical race theorists, on the other hand, have embraced a philosophy of European-style pessimism, dismissing equality under the law as “mere nondiscrimination.” They would replace it with a system of “equity” that treats individuals unequally in order to arrive at equal group outcomes.
Lindsay and Rufo are two of the spearheads leading the charge against “CRT” (what they call “CRT” is up to their discretion; it’s basically anything they don’t like) and they—quite clearly—have no idea what “equity” truly means. By equivocating on the term, they can then begin to redefine it and, when people hear the term, they won’t think of the original meaning, they will think of the new meaning that they have manufactured. (This is pretty much what Rufo has done with CRT.)
Back in January, I wrote on the distinction between “equity” and “equality” and what it means in the context of public health.
There is a distinction between “equity” and “equality.” For instance, to continue with the public health example, take public health equality and public health equity. In this instance, “equality” means giving everyone the same thing whereas “equity” means giving individuals what they need to be the healthiest individual they can possibly be. “Strong equality of health” is “where every person or group has equal health“, while weak health equity “states that every person or group should have equal health except when: (a) health equality is only possible by making someone less healthy, or (b) there are technological limitations on further health improvement” (Norheim and Asada, 2009). But we should not attempt to “level-down” people’s health to achieve equity; we should attempt to “level up” people’s health, though. That is, it is impossible to reach a strong health equality (making all groups equal), but we should—and indeed, have a moral responsibility to—attempt to lift up those who are worse-off. Poverty is what is objectionable, inequality is not. It is impossible to achieve true equality between groups, but we can—and indeed we have a moral obligation to—lift up those who are in poverty, which is, also a social determinant of health (Braveman and Gottlieb, 2014; Frankfurt, 2015; Islam, 2019).
We achieve health equity when all individuals have the same access to be the healthiest individuals they can be; we achieve health equality when all health outcomes are the same for all groups. Health equity is, further, the absence of avoidable differences between different groups (Evans, 2020). One of these is feasible, the other is not. But racism does not allow us to achieve health equity.
So, basically, the distinction is that equality means giving people the same things whereas equity means ensuring people are not held back to be the best they can be. We can say that health inequities are differences in health that are unjust, avoidable, and unfair (Sudana and Blas, 2013) and they are systematic, unfair, and avoidable differences between social groups (McCartney et al, 2019). Social justice efforts that attempt to bring down barriers that impede people from becoming the best they can be is imperative to a fair and equitable society, but this does not mean that efforts to make society more equitable toward social groups is an effort to make society more equal—it’s about making society more equitable where making society more equal is just a byproduct of making society more equitable. So, in the end, “inequities” refer to differences between groups that are avoidable, unjust, and unfair (see also Benjamins and De Maio, 2021).
In her new book, behavioral geneticist Paige Harden (2021: 120-125) has a discussion on “equity” where quotes Conley and Fletcher who claim that “heritability” estimates are a necessary but not sufficient measure of fairness (that is, a measure of an equitable society) in a society. I’ll discuss this in my review of the book, but for now, I will discuss her figure 8.2 on page 123. She shows a photograph of her daughter’s pre-K sign which states “Fair isn’t everybody getting the same thing. Fair is everybody getting what they need to be successful.” This perfectly embodies what equity is and how it is distinct from equality. The key phrase here is “what they need to be successful” and we can liken that to social advantage/disadvantage—certain social groups do not have what is needed to be successful, which, in this case, would be being the healthiest person they can be. Since they lack what they need to be successful and the lack of what they need is systemic (think food deserts/swamps), then they do not have what they need to be successful, meaning that this is an inequity. (This may well be one of the only good things I have to say about this book.)
Braveman (2003: 182) succintly defines what “equity” means:
Equity means fairness (7-10) or justice (8-10). Because these terms are open to interpretation, an operational definition is needed to guide measurement in diverse settings. In operational terms, pursuing equity in health can be defined as striving to eliminate disparities in health between more and less-advantaged social groups, i.e. groups that occupy different positions in a social hierarchy (8). Health inequities are disparities in health or its social determinants that favour the social groups that were already more advantaged. Inequity does not refer generically to just any inequalities between any population groups, but very specifically to disparities between groups of people categorized a priori according to some important features of their underlying social position. For example, individuals may be grouped by their income or material possessions, or by characteristics of their occupations, education, or geographic location, or by their gender, race/ethnicity, or religious group. What all of these factors have in common is that they often are strongly associated with different levels of social advantage or privilege as characterized by wealth, power, and/or prestige (8).
From these definitions and the discussion I have given, it is clear that equity is conceptually distinct from equality.
Since racism is a cause of health problems, then by eliminating racism, we can then ensure health equity. CRT is a “race-equity methodology” (Ford and Airhihenbuwa, 2010), and so, by applying CRT to issues of public health, and by attempting to ameliorate racist attitudes which can and do get “under the skin” to cause differences in physiology (see Sullivan, 2015), then if we eliminate racist attitudes, then we can begin to achieve racial equity. We know that experiencing racism causes accelerated biological aging (i.e., shorter telomere length; Shammas, 2012) and we know that black women in the 47-55 age group were 7.5 years “biologically older” than white women (Geronimus et al, 2011). Thus, racism is a driver of racial health disparities and if we are to achieve racial equity, then we need to eliminate racism. We can use the framework of CRT (which accepts race as a social construct) to understand how and why racist attitudes are had and how and why they are driven by ignorance. Experiencing racist attitudes changes physiology and makes it more likely for the one experiencing the racist attitude to acquire disease states in the future, which would have been a direct outcome of experiencing racist attitudes.
If systemic biases are removed against certain groups (like how doctors are hold unconscious biases against blacks; Hoberman, 2012, and like how medical students believe that blacks have a higher threshold for pain; Hoffman et al, 2012), then we can achieve health equity. If health EQUITY is the ABSENCE OF systemic health disparities (differences in health between and within groups that are unfair, avoidable, and unjust), then we achieve health equity by eliminating systemic health disparities—that is, disparities caused by racism and disparities caused by social determinants of health (Braveman and Gruskin, 2003). Once all groups are not impeded by social goings-on (like living in food deserts/swamps which predict obesity; Cooksey-Stowers, Schwartz, and Brownell, 2017) that force them to not be their best, then we will have achieved ‘equity.’
When public health researchers speak of health equity, they are not operating under the assumption that they will equalize outcomes within and between groups. They are operating under the assumption that they will need to bring down the barriers that impede one to be the healthiest person they can be. In all of my years reading public health research, I have never once read a call for EQUALITY in health; this is just not a feasible position. But EQUITY in health is, and once we begin to change what causes INEQUITIES (health, educational—any kind), then people are no longer held back by (social) circumstances outside of their control, impeding their health, education, etc.
Therefore, the distinction between “equity” and “equality” is: “equality” is making everyone the same or ensuring they get the same things, whereas “equity” is ensuring that people are not held back to be the best person they can be. The distinction between the two concepts that I have drawn up here is very clear. Achieving equity—real equity and not the Lindsay-Rufo strawconcept—is a moral imperative and we, indeed, should attempt it. But achieving equality is just not possible; we would pretty much need to level-down higher groups. The point is, social factors (like racism) should not impede people to be their best and so, we need to eliminate factors that lead to INEQUITIES of ANY kind—be it in public health, education—to achieve a just society. Really loosely, equity can be said to be about fairness but it is more complicated than that, as Braveman’s conceptual discussions show.
All in all, we live in a racist society and racist attitudes affect health which lead to health inequities—that is, differences that cannot be said to be biological; they are differences between social groups that are unfair, unjust, and avoidable and to change these health inequities between social groups (i.e., races, social classes), then people’s attitudes need to change, as the one who is affected by the attitudes physiology can change based on how they take certain statements. Differences between groups that have arisen as part of their position in society that then cause differences in social outcomes are completely avoidable, like differences in obesity between social classes and races (their access to food is impeded by societal factors). And so, to achieve equity—that is, social justice—then we must eliminate any and all systemic barriers that cause said health inequities within and between groups. Equity in health and education are good things, and to strive to reach these goals, we need to change our attitudes as a society towards certain groups. We need to do what we can to achieve feasible goals to ensure that everyone is as healthy as physically possible and that people are not unhealthy due to systemic reasons.