A Renewed Call for Health Equity

Graduate Division

UCSF Health recently launched a campaign for diversity and inclusion in light of the current political climate and national concerns over immigration. In an accompanying article, these issues were presented under the banner of “discrimination”: UCSF strives to provide high quality care to all people. At the center of this campaign is a new colorful poster expressing this support for “all.”

All races.

All religions.

All countries of origin.

All sexual orientations.

All genders.

All ethnicities.

All abilities.

We stand with you.

This long list of differences notwithstanding, there is one form of difference that is noticeably missing: social class. Do we really believe that socioeconomic status matters little in our current era? Have we finally moved beyond class?

With economic inequality at an all-time high, it makes little sense to ignore differences in optimal outcomes across socioeconomic groups.

Basic starting differences in income, education, and cultural capital shape who gets ahead and why in our ever increasingly competitive world. For matters of health, decades of research on the social determinants of health has confirmed that social class does indeed make a difference over the life course.

Poverty is associated with poorer health outcomes, and low socioeconomic status is one of the strongest predictors of all-cause mortality.

Under the current policy imperative of cost containment, the past few months have witnessed renewed political attack on public programs and social services for the poor and needy. This is evidenced by recent proposals that strive to make deep cuts to Medicaid.

Although the future of Medicaid is still uncertain, the overall sentiment towards this public insurance program and its recipients has hardly been neutral. Social class surely continues to make a difference today, and its connection to health status is reemerging as a serious topic worthy of consideration.

To return to the UCSF Health campaign, what does the omission of class – one of the most powerful drivers of health, security, and social outcomes – say about the campaign’s treatment of difference overall?

Beyond socioeconomic status, don’t “all” people have a race, religion, country of origin, sexual orientation, gender, ethnicity, and ability, and shouldn’t “all” differences be respected and treated equally?

In divorcing difference from critical issues such as political power, economic resources, and social status, difference is ultimately reduced in a way that may compromise efforts towards equity. It is politically safer to discuss social difference under the banner of “equal treatment” than to consider unequal distributions of power and resources.

It is also exceedingly difficult to ignore issues of power and resources with class-based differences, as class is directly defined by an overarching socioeconomic order. By omitting class from the poster’s list of differences, these critical concerns are downplayed in favor of “all” people regardless of need, disadvantage, or vulnerability.

Difference matters not because we are all already equal – although this remains a laudable goal to continue to work towards – but because in our current context some groups are clearly doing better than others.

Some face extreme social hardship and stigmatization; others have experienced generations of historical disenfranchisement; and some are publicly attacked on the national political stage. Some groups do not experience these conditions.

Combating inequity in the face of heightened political attention should mean centralizing differences, with a particular commitment to supporting people who experience disadvantage.

In her definition of health equity, Director of the UCSF Center on Social Disparities in Health Paula Braveman puts the issue thusly:

“Pursuing health equity means striving for the highest possible standard of health for all people and giving special attention to the needs of those at greatest risk of poor health, based on social conditions… Health disparities are inequitable, even when we do not know the causes, because they put an already economically/socially disadvantaged group at further disadvantage with respect to their health."

Special attention here does not denote the equal treatment of all people, without regard to difference: rather, striving for health equity suggests targeted support for those who are at a social disadvantage, with regard to difference. This is a critical distinction.

Achieving health equity will require that we be clear about social differences that matter, how and why they matter, and what we as researchers, providers, administrators, and students can do to combat inequities in health and health care.

Viewed in this light, the campaign fails to acknowledge the complexities of our current problem, including how and why immigrants have come under attack. Within the broader political discourse, attacks on immigrants stem from the belief that they are poor and uneducated, unskilled laborers, ideological extremists, and unable to make positive contributions to American society. If UCSF truly stands for all people, including immigrants, then this should mean standing for those who need it most.

UCSF should stand more boldly with those on the margins. This would require recognizing and centralizing difference, not smoothening it away under concern for “all” people.

We stand with undocumented immigrants.
We stand with the poor and needy.
We stand with African Americans.
We stand with Muslims.
We stand with women.
We stand with gender and sexual minorities.
We stand with people with disabilities.
We stand with domestic workers and day laborers.

How can we ever expect to achieve equity if we continue to flatten the very differences that make social difference matter in the first place?