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Swimming Against the Tide

Challenges in Pursuing Health Equity Today

Braveman, Paula A., MD, MPH

doi: 10.1097/ACM.0000000000002529
Invited Commentaries

The term “health equity” has moved from obscurity to the mainstream, creating new possibilities for those who aspire to a world in which everyone has a fair and just opportunity to be healthy. One can now talk explicitly about health equity. The newfound acceptance, however, carries a risk: loss of meaning. Recognizing the need for a common understanding of the core concepts, the Robert Wood Johnson Foundation has promoted a definition that prioritizes being sufficiently concrete to guide action. Lack of conceptual clarity is, unfortunately, not the only challenge in pursuing health equity. Another challenge is the lack of respect for fundamental ethical and human rights principles—cornerstones of health equity—displayed almost daily by those in positions of power, including the president; this lack of commitment to fundamental values has an insidiously toxic effect because many people assume that presidential views must be legitimate. Yet another challenge is lack of imagination. Pursuing health equity inevitably requires swimming against the tide of prevailing forces that exclude, marginalize, or otherwise disadvantage groups of people based on their skin color, wealth, gender, disabilities, sexual orientation, gender identity, religion, or other characteristics tightly linked with social advantage. To persist in swimming against the tide, the end goal and the reason for pursuing it must be very strong and very clear. Academic medicine can play an important role as a powerful force in setting norms and shaping the values and attitudes of medical students, attending physicians, and research faculty.

P.A. Braveman is director, Center on Social Disparities in Health, and professor of family and community medicine, University of California, San Francisco, San Francisco, California.

To read other New Conversations pieces and to contribute, browse the New Conversations collection on the journal’s website (, follow the discussion on AM Rounds ( and Twitter (@AcadMedJournal using #AcMedConversations), and submit manuscripts using the article type “New Conversations” (see Dr. Sklar’s announcement of the current topic in the November 2017 issue for submission instructions and for more information about this feature).

Funding/Support: None reported.

Editor’s Note: This New Conversations contribution is part of the journal’s ongoing conversation on social justice, health disparities, and meeting the needs of our most vulnerable and underserved populations.

Other disclosures: None reported.

Ethical approval: Reported as not applicable.

Correspondence should be addressed to Paula Braveman, University of California, San Francisco, 3333 California St., Suite 365, San Francisco, CA 94143; telephone: (415) 476-1259; e-mail:

Twenty years ago in the United States, both within and outside the health sector, using the term “health equity” would reliably elicit a blank stare. The phrase “social determinants of health” was arguably a little less obscure but sounded academic to most audiences—including most academics. Since then, acceptance of both terms has followed a remarkable upward trajectory. Both are now mainstream in public health, medical care (at least in primary care), and increasingly even among private and public third-party payers.

The rapid transition of “health equity” and “social determinants of health” from obscurity and stigma to daylight and respectability has opened up tremendous possibilities for those who aspire to a world in which everyone has a fair and just opportunity to be as healthy as possible. It is a great advantage that we can now talk and write explicitly about health equity and the social determinants of health, rather than tiptoeing around the terms and relying on less foreign-sounding or less stigmatized but also less explicit substitutes.

The newfound acceptance and widespread use of these terms, however, comes with a risk: They could lose their meaning. If you ask 100 individuals from public health, medicine, and medical care financing what health equity means, you will probably hear 100 answers, most of which will differ on substance and not just semantics. Most of those 100 individuals will not refer to the social determinants of health in their definitions of health equity. If you ask them to define the social determinants of health, many will list health care or health-related behaviors; only a few will likely mention the more fundamental social determinants of health such as wealth, education, and racism. Without shared definitions that reflect a common understanding of the core meaning of health equity and the social determinants of health, these terms could become little more than empty rhetoric. One of the main challenges we face in pursuing health equity, therefore, is to be clear about what we mean when we use these terms. Recognizing these risks, the Robert Wood Johnson Foundation (RWJF) recently launched a series of issue briefs on a range of issues related to health equity, devoting the first brief to defining the term, as follows:

Health equity means that everyone has a fair and just opportunity to be as healthy as possible. This requires removing obstacles to health such as poverty, discrimination, and their consequences, including powerlessness and lack of access to good jobs with fair pay, quality education and housing, safe environments, and health care. For the purposes of measurement, health equity means reducing and ultimately eliminating disparities in health and its determinants that adversely affect excluded or marginalized groups.1

While there are other good definitions of health equity, the crafting of this definition was driven by particular concerns about being sufficiently concrete and prescriptive to guide action. High priority was placed on operationalizing the definition’s more general first sentence, which has the appeal of being brief and intuitive but, like many other definitions that ring true in abstract terms, provides inadequate guidance for taking action. The second sentence attempts to address this by explicitly invoking key fundamental social determinants of health—namely poverty, discrimination, and their consequences. The final sentence addresses measurement, reflecting recognition of widespread lack of clarity both about how to measure progress toward health equity and about the importance of measurement for accountability.

Formal definitions aside, health equity has two essential core elements: (1) improving the health of those social groups who have historically been marginalized, excluded, or otherwise placed at a social disadvantage; and (2) doing so by improving not only health care but also the social determinants of health—including the most fundamental determinants—that affect these groups. The social determinants of health are defined in the RWJF brief as “nonmedical factors such as employment, income, housing, transportation, child care, education, discrimination, and the quality of the places where people live, work, learn, and play, which influence health.”1 The most fundamental social determinants—such as wealth, power, and discrimination—are also sometimes called “upstream determinants,” invoking a metaphor in which going upstream means seeking to address the most fundamental underlying causal factors of a health problem that eventually manifests “downstream” when detected clinically.

Lack of clarity about concepts is not, unfortunately, the only challenge faced in pursuing health equity today. A more deeply rooted and daunting challenge is cynicism and lack of respect for ethical values and for human rights. Equity means justice; it is a value, firmly rooted in widely accepted ethical and human rights principles. Insufficient commitment to ethical values and human rights has long existed, and we have been on a relentless path toward increasing economic inequality for decades—income inequality in the United States is now at its highest level since the 1920s.2 Wilkinson and Pickett3 hypothesize that greater inequality within a society leads to less empathy of the haves for the have-nots, as the lives of rich and poor become increasingly separate. A lack of empathy may in turn lead to less willingness to invest in initiatives that benefit all members of society. In addition, the current historical period may be unique, at least during the last half-century, for the lack of respect for fairness, justice, honesty, truth, and compassion that is exemplified at the highest levels of political leadership of this nation. This creates an insidiously toxic situation because many people assume that views implicitly or explicitly supported by the president of the United States must be legitimate.

Another huge challenge in pursuing health equity today is failure of our imaginations. Who during the 1920s believed that Social Security would be enacted in 1935? Who believed that so many people—both black and white, but mostly black—would have the courage to put their lives, limbs, and livelihoods on the line during the 1950s and 1960s to struggle for civil rights? Even more improbably, who would have predicted that the impact of those struggles would be seen in the enactment of major civil rights legislation in the mid-1960s? Or that Medicare and Medicaid would be enacted in 1965? Or that the Vietnam War would finally end as a result of many years of antiwar protests? Or that the United States would elect an African American president in 2008 and again in 2012? In stretching our imaginations, we must of course also face the challenge to be guided by current knowledge, to consult widely enough, and to carefully assess both the possibilities and risks of alternatives.

Academic medicine can play an important role in pursuing health equity. It is a powerful force in setting norms and shaping the values and attitudes of medical students, their attending physicians, and research faculty whose publications may reach far and wide.

In 1995, Birdsall and Hecht published a report called “Swimming Against the Tide: Strategies for Improving Equity in Health.”4 The metaphor they invoked remains both vivid and apt. The notion is that to pursue equity, one must almost invariably swim against the tide of prevailing forces—forces that exclude, marginalize, or otherwise disadvantage groups of people based on their skin color, wealth, gender, disabilities, sexual orientation, gender identity, religion, or other characteristics tightly linked with relative social advantage. Swimming against the tide means swimming upstream against the tidal force, trying to address the most fundamental causes of health inequities at their sources. To persist in these efforts, we must not only be strong but also very clear about where we are headed and why.

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1. Braveman P, Arkin E, Orleans T, Proctor D, Plough A. What Is Health Equity? And What Difference Does a Definition Make? 2017.Princeton, NJ: Robert Wood Johnson Foundation.
2. Desilver D. U.S. Income Inequality, on Rise for Decades, Is Now Highest Since 1928. 2013.Washington, DC: Pew Research Center.
3. Wilkinson LR, Pickett KP. The Spirit Level: Why Greater Equality Makes Societies Stronger. 2010.New York, NY: Bloomsbury Press.
4. Birdsall N, Hecht R. Human resources development and operations policy (HROWP 55)..Swimming Against the Tide: Strategies for Improving Equity in Health. 1995. Washington, DC: World Bank.
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