Beyond The Fence: Unpacking Equality, Equity and Justice

Beyond the Fence: Unpacking Equality, Equity, and Justice for Health Transformation - Draft 1.0

By Mani Vannan | Digital Foundry 360

Recently, a fascinating  LinkedIn post from  Dr. Yolanda Wimberly, Chief Health Equity Officer at Grady Health System, sparked a deep dive into the nuanced concepts of equality, equity, and justice. Dr. Wimberly's sharing of a thought-provoking political cartoon ignited a conversation that I believe is critical for anyone working towards a healthier, more just society.

Her question, "I am curious how others interpret this picture? I have been asking people and I gave gotten so many different answers," highlighted the inherent complexities and diverse perspectives around these seemingly simple terms.

As we move forward in the vital work of health equity, understanding these distinctions isn't just academic – it's foundational to impactful change. Let's explore the journey from equality to justice, and why the path is often so contentious.

Part 1: The Classic View – Understanding the "Fence"

Many of us are familiar with the widely used illustration that distinguishes equality from equity, often depicting individuals of different heights trying to watch a baseball game over a fence:

 The classic "Equality vs. Equity" visual

And when extended, the concept of Justice transforms the approach even further:

 Extending the concept to Justice, where the systemic barrier is removed

• ● Equality: Giving everyone the exact same resources or supports. In the visual, everyone gets one box to stand on. While seemingly "fair" on the surface, this approach often fails because it doesn't account for pre-existing disadvantages. The tallest person might see fine, but the shortest person still cannot, perpetuating unequal outcomes.
  
• ○ In Health: This translates to providing everyone with the same access to a clinic, the same health information pamphlets, or the same public health campaigns, regardless of their unique circumstances.
  
• ○ The Conflict: Those who benefit from this "equal" starting point may not understand why others still struggle, potentially blaming individual effort rather than systemic barriers.
  
• ● Equity: Providing differentiated resources or supports to individuals based on their needs, with the goal of achieving a fair and just outcome or level of access. In the visual, individuals receive boxes of varying heights so that everyone can see over the fence. This acknowledges that an equal starting point isn't always fair if the playing field itself is uneven.
  
• ○ In Health: This means providing interpreters for non-English speakers, mobile clinics for rural communities, culturally competent care, or targeted programs for specific health challenges. These are "accommodations" designed to level the playing field.
  
• ○ The Conflict: This step often becomes controversial. Those who perceive themselves as "losing" their unearned advantage (e.g., giving up their "extra" box,

• or seeing resources directed elsewhere) may view equity as "special treatment" or "unfair," leading to strong resistance.
  
• ● Justice: This goes beyond providing supports and fundamentally addresses the root causes of inequity by dismantling the systemic barriers themselves. In the visual, the fence is removed entirely, making boxes unnecessary. It's about transforming the system so that the "accommodations" are no longer needed.
  
• ○ In Health: This is where we tackle the Social Determinants of Health (SDOH) at a systemic level: addressing poverty, structural racism, lack of affordable housing, food deserts, environmental pollution, and discriminatory policies. It's about ensuring everyone lives in conditions conducive to health.
  
• ○ The Conflict: This is often the most controversial step because it requires dismantling existing structures, power dynamics, and sometimes acknowledging historical injustices. It demands systemic transformation, which challenges the status quo and can feel threatening to those who have benefited from it.
  

Part 2: The Alternative View – A Race for Understanding

The political cartoon shared by Dr. Wimberly presents a starkly different lens on this discussion, and it's this image that particularly intrigued me and prompted further reflection.

The political cartoon on "Equality vs. Equity" that sparked Dr. Wimberly's LinkedIn post)

• ● "Equality" (Cartoon's View): Depicts a race where everyone "starts first," with cars labeled "Opportunity," "Access," "Effort," "Hope," and "Success." This perspective champions a pure meritocracy, suggesting that given an equal starting line, individual drive determines success.
  
• ● "Equity" (Cartoon's Critique): Shows the same cars labeled "Apathy," "Complacent," "Idle," "Dependency," and "Victim," leading to "EVERYONE FINISHES LAST." This view often interprets equity initiatives as fostering reliance, stifling individual initiative, and ultimately leading to collective failure.
  

This cartoon illustrates a common and powerful counter-narrative to health equity efforts. It reflects concerns that interventions aimed at equity can undermine personal responsibility or create unintended negative consequences.

Part 3: The Deeper Philosophical Question – Why Societies Rise and Fall

Dr. Wimberly's curiosity about these varying interpretations touches upon something even more profound: the underlying forces that shape societies, relationships, and even individuals. From a philosophical standpoint, the rise and fall of civilizations, like the ancient Maya I recently had the privilege to visit, offer powerful lessons.

These dynamics apply at all scales:

• ● Values: The fundamental principles a society (or individual, or family) prioritizes. A conflict in values – such as how "fairness" is defined (e.g., "everyone gets the same" vs. "everyone gets what they need to thrive") – can create internal tension and instability.
  
• ● Adaptive Intelligence: The capacity to learn, innovate, and adjust strategies in response to changing conditions. When a society (or relationship, or individual) becomes rigid, fails to acknowledge new realities, or ignores the experiences of marginalized groups, its adaptive capacity erodes.
  
• ● Resource Allocation, Decisions & Actions: How resources (wealth, time, attention, emotional energy) are distributed, and the choices made by leaders and individuals. Inequitable or unsustainable allocation, coupled with poor decisions, can lead to systemic stress
  

Crucially, these processes are often characterized by a "lag effect." Deterioration is slow, cumulative, and often imperceptible from day-to-day. Societies (or relationships) can absorb a surprising amount of stress. But once a critical threshold is crossed, or a significant external shock occurs, the decline can feel sudden and precipitous. The "sudden collapse" is often the visible manifestation of years of unseen erosion.

For the Maya, theories of decline include the inability to adapt agricultural practices to changing climate, political fragmentation, and diverting resources from critical needs to elite pursuits – all accumulating stressors leading to a "sudden" inability to sustain their complex civilization in the face of prolonged drought.

Conclusion: A Spark for Dialogue in Health Equity

This exploration underscores that advancing health equity is not merely a technical challenge; it's a deeply philosophical and societal one. It requires:

• 1. Shared Understanding: Moving beyond simplistic definitions to a nuanced comprehension of equality, equity, and justice.
  
• 2. Adaptive Intelligence: Continuously learning, adapting strategies, and integrating diverse perspectives to address root causes.
  
• 3. Values Alignment: Grappling with fundamental disagreements on what constitutes a "fair" and "just" society.
  
• 4. Long-Term Vision: Recognizing that systemic change involves addressing deep-seated issues with complex lag effects, demanding patience, persistence, and a willingness to dismantle existing "fences."
  

Dr. Wimberly's willingness to engage with challenging perspectives, like that presented in the Ramirez cartoon, is a testament to the comprehensive approach needed for true health transformation. It suggests a leader who isn't just advocating for equity but is also keen to understand and navigate the philosophical and practical barriers to its achievement.

I am excited by the opportunity to collaborate with Dr. Wimberly and Crystal on this vital conversation, especially given Grady Health System's commitment to equity, as highlighted in their "Where Equity Matters" initiative.

Grady Health System: "Where Equity Matters"

Mani Vannan | Digital Foundry 360

 

This blog is meant to be a Thought Spark to ignite a self inquiry and a collaborative action leveraging our collective intelligence and collective intent to shape the shared purpose.

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