Are we striving for equity, or equality?

Why do some people baulk at the concept of equity? Is it because they don’t like the idea that some individuals or groups might somehow get ‘more’ resources or opportunities than they do?

The terms equity and equality are used a lot in discussions about access to dental care, particularly in terms of ways in which we need to focus attention on disparities in the burden of disease and access to care. And for many people, the terms are used interchangeably to mean the same thing.

Equality means that individuals or groups are given the same. The same resources, or the same opportunities.

Equity on the other hand recognises that individuals or groups sometimes have different needs based on their particular circumstances, and therefore the aim is to allocate opportunities or resources to reach an equal outcome.

Subtle differences, but important.

Margaret Thatcher once said that equality is an unnatural condition that can only be enforced by the state. This was meant to be a critique of efforts to achieve equality, but it makes an important point – we are not all born equal. This is most obvious in physical characteristics like height, sex or even hair colour. There is research that shows that income is related to factors such as height, stature or facial appearance, and we know that income inequality is linked to a range of health conditions, including for dental diseases. Genetics also plays an important role in disease susceptibility.

So it is clear that we start on unequal footing, at the mercy of the genetic lottery of life. So why is it so controversial to consider ways to mitigate some of these differences in order to achieve more equal health outcomes? There is no doubt that some of this is rooted in ideas about personal responsibility and health.

Look at the image below. Two children trying to get some apples. Through no fault of their own, the child on the right will always get less apples than the child on the left. This is inequality – the outcomes are fundamentally different and unfair. Unfair because it is not the fault of the child on the right. It is just luck of the draw.

In the next image we see what an attempt at equality might look like. Both children have been provided with the same resources – a ladder of the same size. This is how many people want to see the equality/equity issue resolved – the same resources or opportunities for everyone, regardless of their circumstances. But as we can see here, all this has done is substantially assist the child on the left but made a marginal or even zero difference to the child on the right. And no amount of individual responsibility can change the outcome here.

Next we see an attempt at equity – providing the child on the right with a taller ladder to better access the apples. And to a large extent that has gone a long way to ensuring a more equal outcome – access to apples.

But one of the interesting things to note in this example is that the tree is lopsided, with more apples on one side than the other. So even now, the child on the left has access to more apples. It might be easy to think that this is just nature at work, but it belies the fact in so much of our environment is intentionally shaped to advantage certain groups over others. What we might not be seeing in this image is the work that the farmers might have employed to ensure a higher yield (and therefore a substantial lean) on one side of the tree. And this is part of the hidden differences that go beyond some of the physical that really get to the heart of health disparities.

So in order to truly achieve justice, it might be necessary to reshape the environment in some manner – whether through physical change as we see with the tree, or through systems and process, particularly of power. This is to mitigate some of the structural inequality that exists that leads to health disparities in the first place.

What does this mean for oral health? We know that the burden of oral diseases is felt disproportionately across the community. People living with socioeconomic disadvantage, low income or lower education tend to have poorer oral health outcomes. I touched on some of the causes of this in the podcast on commercial determinants of health, highlighting how commercial practices have distorted our lived environment in ways that lead to this disproportionate disease burden. And we also see it in the distribution of dental practitioners, with a greater number per capita in metropolitan compared with regional and rural areas, and a greater number in suburbs of greater socioeconomic advantage.

An approach based on equality would see systems designed to fund or improve access to dental care spread in a uniform way across the community, regardless of circumstance. An approach based on equity would see systems that target individuals or groups that experience the greatest health disparities to ensure that they have a better chance to achieve the same level of oral health as their more advantaged counterparts.