The CDC defines health equity as the “state in which everyone has a fair and just opportunity to attain their highest level of health.” Similarly, the World Health Organization describes it as “achieved when everyone can attain their full potential for health and well-being.”
Health equity is largely shaped by social determinants of health (SDH): the social, economic, and environmental conditions that influence the health of individuals and populations. SDH can manifest as education, economic status, racism, gender, and more. These nonmedical factors, which describe how and where people live, have a significant impact on a person’s health.
Social determinants are not random. SDH result from structural factors, government policy, and historical practices that shape who has access to quality schools, stable housing, safe neighborhoods, good jobs, and health care. Policies like redlining, discriminatory lending, and unequal school funding have left lasting marks on communities of color, and their effects compound across generations. Researchers call this structural racism, and recent work on immigrant health and structural stigma shows how these systems shape health outcomes both between and within marginalized groups (Misra et al., 2021; Mitchell et al., 2021). In other words, health disparities have less to do with individual choices than with the conditions people are born into, grow up in, and live in.
Neighborhoods offer one of the clearest views of how nonmedical factors shape a person’s health. Neighborhoods differ in walkability, green space, healthy food options, and safety, and those differences tend to track neighborhood income and racial makeup (Diez Roux, 2016). Research on stress and the body points in the same direction. In a study of 325 African American women, trained observers rated visible signs of disorder on each woman’s block, such as graffiti, vandalism, and abandoned buildings. Women in more disordered neighborhoods reported poorer health, and that link was partly explained by higher levels of chronic inflammation, a biological marker of stress, even after accounting for family income and neighborhood disadvantage (Lei & Simons, 2021). The associations were modest, but they suggest that neighborhood conditions can affect the body via bioindicators.
Policy is where health equity either becomes real or stays a slogan. Public health researchers argue that policies should stop trying to “fix” marginalized communities and instead go upstream, targeting the systems of stigma and discrimination that create disparities in the first place (Mitchell et al., 2021). Doing that well takes better information. Gaps in national data, especially on children, immigration history, and gender and sexual identity, make it hard to see which communities are being missed (Zambrana et al., 2021). An example of health policy is Medicaid expansion under the Affordable Care Act, which opened coverage to more low-income adults. A KFF review of 65 studies found it helped narrow, but not eliminate, racial and ethnic gaps in health coverage (KFF, 2020). Furthermore, researchers found that coverage alone is not enough to predict health outcomes due to the many other social and economic factors that shape an individual’s health.
Policy works better when the people it is meant to serve help shape it. A review of 45 studies of Indigenous-focused health research found that practices like honoring community knowledge, being accountable to community partners, and supporting self-determination are central to a more equitable approach, partly because outside experts can overlook local knowledge and end up worsening the disparities they set out to address (Narasimhan & Chandanabhumma, 2021). Listening can also be built into the research itself. In a West Baltimore project, residents used group storytelling and mapping to point out the assets in their neighborhoods, and they named their homes and faith institutions as the most important. The evaluators concluded that the initiative’s success would depend on residents feeling personally connected to it and having it located in proximity (Fakunle et al., 2021).
Health equity means everyone has a fair and just opportunity to be as healthy as they can be, and that opportunity depends heavily on conditions that medicine alone can’t control. Factors such as where individuals live, the policies that shape one’s coverage, and neighborhoods all influence health long before anyone steps into a clinic. Closing these gaps takes work at every level of intervention.
Better data can show who is being missed, policies can be designed and evaluated with equity in mind, and communities can be treated as partners rather than subjects. Achieving health equity requires addressing the underlying barriers that prevent individuals and communities from accessing the resources they need to live healthy lives. By prioritizing fairness, accountability, and collaboration, we can move toward a healthcare system that provides everyone with the opportunity to achieve their highest level of health.
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This blog post was written by Andrew Bjork, a student at William & Mary in Williamsburg, VA.
