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Writer's pictureChristie Roberts
Jul 2410 min read

Health Equality, Equity and Justice

In our world, we know that health inequalities exist, and that they have drastic impacts on access, experience and outcomes in health for both individuals and populations. One of the most obvious inequalities is in life expectancy (LE- what it says on the tin) and perhaps more importantly, healthy life expectancy (HLE- the time spent in a state of percieved 'good' or 'very good' health).

Oxford, as an example, is generally known for being an affluent area, with house prices equivalent to London, higher than average wages, and large populations of students and academics. Only (and I say 'only' scathingly, because really the figure should be zero) 11% of the population of Oxford live in deprived areas, compared to 20% nationally in England, Similarly, 21% of children live in poverty compared to 29% nationally (Oxford City Council, 2024) and this is reflected in a higher than national average LE for both men and women in Oxfordshire compared to England- for men, 81.1 vs 78.9 and for women 84.8 vs 82.8 (Office for Health Improvement and Disparities, 2023).

However, the Bureau of Investigative Journalism identified a shocking 15 year difference in LE for men living in an OX4 postcode compared to men in an OX1 postcode, with men in the more deprived OX4 area typically dying at 75 years old compared to 90 in OX1 (Bureau of Investigative Journalism, 2019). That is shocking, and relflects something known as the social gradient (The Kings Fund, 2022) whereby as deprivation increases, LE decreases. The causes of lower LE and HLE are multifaceted, but most likely come down to social determinants of health and the impact of health equity on these determinants (keep you eyes peeled for a full post on social determinants, but I will give a quick run down here for context).


I think most of us will recognise the image below, which shows the reality of how resources are distributed which leads to differences in people's experiences- those with more resources have a better experience. I'll get into each aspect of equality, equity and justice (which they call liberation in this graphic) in more detail below.


(Interaction Institute for Social Change, no date)


Social determinants

The conditions in which we are born, live, work and age have clear impacts on health and wellbeing, and these are referred to as wider, or social determinants of health. In 1991, Dahlgren and Whitehead developed the 'rainbow model' for wider determinants of health (seminal in the world of public health, but you either love it or you hate it...) which explores a range of factors from an individual level to a population level.


(Adapted from Dahlgren and Whitehead, 1991).


The factors in the centre are the individual level factors. In red, we see constitutional factors that may change our personal disposition to ill health. For example, older people are known to have higher rates of cancer by virtue of the fact that they've had longer for cells to mutate, and may have experienced additional carcinogenic exposures in this time (Cancer Research UK, 2023). Other conditions affect specific genders- biological women have 0 risk of prostate cancer, and biological men have 0 risk of uterine cancer. These constitutional factors are considered immutable- i.e these risks cannot be modified.


Every other layer in the wider rainbow can be considered mutable or modifiable. Which is great, because theoretically, we can therefore adapt these factors to generate the lowest possible risk of illness. In reality, it's sadly not that easy, and this is due to the effects of inequality, and generational inequality. It's generally considered that the further out you move within the model, the more difficult it is to obtain change on an individual level.


Orange individual lifestyle factors includes things like smoking. Ar which point, you're probably thinking 'just stop smoking!' and you're right- this would reduce your risk of health problems caused by smoking. However, what if a person smoking has come about because their parents smoked in the house through their childhood, hence normalising the behaviour? What if everyone in your yellow social and community networks smokes, so smoking forms a key part of your social interactions? And finally, the green living and work envionments. How easy is it to stop smoking if a lack of access to health services or education means someone lacks the health literacy to understand the impacts on their health? What if smoking is used as a coping strategy to deal with a stressful work envionment, or lack of work? Suddenly, 'just stop smoking' becomes significantly more difficult, to the point of questioning if this behaviour is modifiable on an individual level? These conditions of living rarely exist in isolation- someone who is unemployed may also live in poor quality or overcrowded housing, and lack access to green spaces and healthy foods. These factors compound to have a massive overall impact on health.


Considerations within the outermost blue section are considered factors at a population level. These could include the location of health services or public transport routes to access these, which are often decided at an ICB level. Similarly, government policy can also shape individual health at this level, for example considering policy and action relating to climate change, air pollution, or access to welfare benefits. These factors are huge beasts, which an individual has minimal influence over yet may still be affected by.


So whilst the concept of modifiable factors is simple enough, it's far from easy.


How does inequality impact on this?

Back to the point of inequality, equality, equity and justice. A health inequality is defined as 'unfair and avoidable differences in health across the population, and between different groups within society' (NHS England, no date). It feels like common knowledge that people are not born equal, and are not afforded the same opportunities in life, but these inequalities can be so stark and cover a wide range of factors that ultimately impact on health and wellbeing. These include:


  • Social determinants of health

  • Behavioural/lifestyle risk factors and general life factors- eg. language barriers to be able to develop health literacy.

  • Quality and experiences of previous care- eg poor prior experiences or experiencing exclusion from services may generate distrust or fear and lead to reduced help-seeking when unwell.

  • Access and availability of services- eg the opening times of the service- would people need to take time off work to access a service? and transport options to access the service.

  • Underlying health status- eg life expectancy, and all the factors that influence this such as deprivation.

(The Kings Fund, 2022)


The impact of these inequalities is poorer health, dimished wellbeing, and lower quality of life. These factors tend to be intersectional, and compund the problems faced. Some inequalities will also be more pronounced across certain groups- for example, those living in rural areas, those who have protected characteristics under the Equality Act 2010 (more info on protected characteristics from LGA here) and groups who are considered socially excluded, such as homeless people (The Kings Fund, 2022).


The most important word in the definition of health inequality is avoidable. These disparities should not exist in a modern world, and no population or individual should systematically be experiencing poorer health. To provide an example- in the absence of health inequalities, every person should have had an equal risk of dying of Covid-19. But instead, mortality rates were higher in more deprived areas, in people of ethnic minorities, and amongst disabled people (The Kings Fund, 2022). Wider determinants, including personal lifestyle factors, and fields of employment and crowded housing, are likely to have contributed to this disparity- all of which are avoidable and mutable contributors to mortality.


How do we fix it?

The opposite of inequality is equality. So is this what we are striving for? It's a good start, but as the image below demonstrates, we can do better.

(Design in Tech Report, 2019)


In achieving equality, we provide everyone with the same resources. Good in theory, but does this not just maintain the distance that had already been estabished between those who have good health and those who don't, because individual and systemic factors are not accounted for? Equality is represented in the diagram above in the bottom left image, and you can see that giving both individuals a ladder does nothing to address that the tree is taller on one side, and have more apples on one side. The system is still skewed towards inequality. I often hear an argument that equality is in fact what we should be aiming for- but this argument fails to recognise that people starting from the same place does not guarantee that they will end up in the same place- hence, health inequalities remain. And no, it's not 'favouritism' to give some people more resources- it's proportionate to their needs.


Speaking of proportionalism, the concept of 'universal proportionalism' introduces us to the concept of equity. Equity brings in the notion of support that is customised to meet the needs of specific individuals or populations that are known to have higher needs, and this approach factors in differences between people (Achieve Brown County, 2021). Shown in the upper right of the image above, each person has been given a ladder. But the person who had been suffering worse outcomes in the 'inequality' scenario has a taller ladder, to compensate for the fact that her side of the tree is still taller. This means that she now has the opportunity to get some apples- but given that there's still significantly fewer apples on her side of the tree, at some point a level of inequality will be reached again.

Universal proportionalism is a concept that promotes a universal level of support whose scale and intensity is proportionate to the level of need or disadvantage (Marmot, 2010). This way, we get around the notion of unfairness, because everyone is getting something, but the people who need more, get more. This principle gets us closer to achieving equity in access, experience, and outcome, but is unlikely to reach full potential. To use the image above again- the tree still has fewer apples on one side, so someone's experience of picking apples is going to be more difficult, despite having the same access to the tree via a taller ladder to reach the apples. Maybe that person has an underlying health condition that means going up and down the ladder multiple times is too exhausting, so they have to stop picking apples sooner than their counterpart, giving them a different experience. Maybe they have caring responsibilities which limits the amount of time they can spend picking, so their outcome remains that they get fewer apples.


Throughout this post, I've hinted towards equity being the end goal we should be achieving. But what if we can do better? What if we can achieve health justice? The reason I've not mentioned justice up until this point is because it's a massive piece of work, which requires engagement at every level- on the ground with individuals, up to decision makers and key stakeholders. The cornerstone of achieving justice is achieving systemic changes that allow for true long term equity in access, experience and outcome (Achieve Brown County, 2021). Shown in the bottom right of the image, you can see that the tree is now level, and has comparable numbers of apples on each side. Because of this, both people now have the same sized ladder- because the system is working with them to ensure they can start in the same place, and most importantly- end in the same place, with equal numbers of apples (icymi- the apples are a metaphor for health). Achieving health justice requires committments from everybody within the system, including those who are not affected by the system and those who maybe benefit from the system status quo, but who recognise that not everyone is afforded the same privilege. It requires campaigning from those with influence, activism from those with lived or living experience, advocacy from people who care about improving health, and listening from those with the power to make decisions and enact changes in the system.


I've only recently become more involved in advocating for health justice, particularly around HIV, by campaigning with Youth StopAIDS. I do not have HIV, so working towards a fairer society and equal opportunity and outcomes for people living with HIV doesn't personally benefit me, but...

1. it's the right thing to do

2. who am I to judge who gets the right to good health and wellbeing?

3. me, or any of us, could become a person living with HIV at the drop of a hat. And if that happened, I'm sure we'd all wish that someone had striven for justice, and worked for reducing stigma and improving care.


In fact, I got involved with campaigning after an HIV exposure. During this experience following my exposure, I benefitted from massive amounts of privilege which limited the influence of potential inequalities within healthcare: I had adequate education and health literacy to know how and when to seek treatment. I had timely (and free) access to the medication I needed to prevent HIV. I was offered follow ups that I could attend without it disrupting my work or income. I was given all the tools and support I needed to promote my health and achieve the best outcome.

Had I acquired HIV following this exposure, I know that this quality care would've continued, in part at least because of my personal circumstances- being white, straight-passing, well educated, in a stable living situation, and having social supports would have contributed to positive experiences that are not afforded to everyone in a similar situation, because we've yet to achieve health justice, or even equity, within the sphere of HIV.


To sum it up...

The sad reality is that despite a theoretically world class health service (God bless the NHS), people do not have the same opportunities to live a healthy and fulfilling life, due to health inequalities. The bleak reality is that achieving equality, equity and justice are mammoth tasks, that require both top down and bottom up pushes for change. I feel like most of my public health posts have an undertone of 'here's a problem, but I don't have a solution', so the best I can suggest is that on a local level, every individual and clinician advocates for themselves and their patients to help flatten hierarchies, demand equitable access, and facilitate proportionate resources for those with greater need.


I hope this is helpful- as always, drop me a message on here on on social media (@christienursing) with any questions, comments or suggestions! All my love,

Christie x


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