Defining Success: Establishing Clarity of Purpose and a Measurement Framework to Advance Health Equity.

Even in public health's early stages, when John Snow first recognized the source of cholera's spread in London, it was clear that social determinants played a critical role in people's health: in this case, where people lived, worked, congregated, and accessed water determined their health outcomes.1 Since then, research has consistently demonstrated that long-standing systemic inequities have put people from socially and economically disadvantaged groups at an increased risk for poorer health outcomes.2–4 Despite such evidence, historically, public health professionals and institutions merely sought to mitigate health disparities primarily through targeted communications and culturally based interventions, suggesting simply that understanding was lacking at the individual level or that cultural variations were somehow leading to unhealthy outcomes. These approaches failed to fully recognize, much less address, the role of environment, community, and society's inherent structures and failings (eg, inequitable distribution of resources, racism, discrimination, and environmental injustice) in producing disparate health outcomes.

In 1978, the World Health Organization (WHO) Alma Ata Declaration asserted that “health is a fundamental human right” and called for all governments, international organizations, and the world community to alleviate health disparities.5,6 In 1991, WHO identified health inequalities as “one of the greatest challenges to public health.” It also suggested that enabling people to adopt healthier lifestyles acknowledges that some groups in society face greater limitations than others and recommended that “sensitive policy making” be used to enable people to live healthier lives.2 Despite such recommendations, approaches to achieving health equity have been predominately indirect, focused on monitoring demographic differences in health outcomes and weighted toward increased access to health care. These approaches address but a fraction of the social determinants of health and overlook the immense value of health promotion and disease prevention in deference to the traditional, more familiar focus on disease treatment.

In 1985, the US Department of Health and Human Services (HHS) initiated formal efforts to move toward health equity by appointing a Secretarial Task Force to comprehensively assess the health of racial and ethnic minorities. This effort produced the 1985 landmark “Report of the Secretary's Task Force on Black and Minority Health,” commonly known as the Heckler Report.7 The report documented needed policy guidance and established a set of milestones for the health equity movement including pivotal legislation, funding, policies, research, and initiatives focused on minority health and health equity.8 It ultimately led to the creation of the HHS Office of Minority Health and resulted in the inclusion of health disparities and achieving health equity as important areas of attention in the Healthy People initiative, the nation's iterative, 10-year plan for addressing the most critical public health priorities and challenges.

Despite the efforts of these policy makers, a variety of economic, political, and health events in the more than 35 years since the release of the Heckler Report have shown that any gains were modest and fragile and that forward progress in advancing health equity can rapidly decelerate and even be reversed. The COVID-19 pandemic has emphasized how inequities have persisted, even worsened, and contributed to additional vulnerability. We have witnessed much worse outcomes to COVID-19 in those who have largely preventable chronic conditions and those who routinely suffer inequities in the social determinants of health. The pandemic has again put health disparities at the forefront of national conversations, making this a critical moment for addressing health equity. It has exposed and exacerbated existing inequities and reminded our nation what John Snow demonstrated so long ago—that place and social circumstances matter.

As we continue these important conversations and strive to achieve health equity, it has become clear that the field of public health cannot go it alone and must take action in partnership with all sectors of society. We propose 2 recommendations on how to enable such collaboration: we must use the same language, and we must use measures that comprehensively integrate the conditions that lead to health.

Health equity's definition has changed over time, drawing ever closer to a more useful and circumspect construct, but not one that is yet universally recognized. Whitehead defined health inequities as “unnecessary and avoidable, ...unfair and unjust”2(p431) differential health outcomes that are due to differences in access, exposure, unhealthy living and work conditions, and behaviors that reflect lifestyle restrictions in part due to limited social position and mobility. Slightly more than a decade later, Braveman and Gruskin defined health equity as “the absence of systematic disparities in health (or in the major social determinants of health) between social groups who have different levels of underlying social advantage/disadvantage.”9 This definition has evolved over time and consequently has been subject to inconsistent application.

In fall 2021, the Office of Disease Prevention and Health Promotion (ODPHP) in the HHS Office of the Assistant Secretary for Health conducted an environmental scan of peer-reviewed literature, federal and state government Web sites, and nongovernmental organizations Web sites to explore how the term “health equity” was defined in the field of public health.10 The findings revealed similarities between many of the definitions, as evidenced by the use of phrases related to “attaining the highest level/standard of health for all people,” provision of “opportunity” to attain their highest level of health, or the “absence of disparities.”

However, the study also clearly suggests that consistency in terminology is needed. For example, adopting a focus on the “absence of disparities” may lead to undue focus on increasing health care equity among populations rather than focusing on the necessary tenets of social justice.6 The recommended definition of health equity should include our nation's historic social context, embrace current social complexities, and factor in those circumstances and contextual issues that define vulnerable populations. For this reason, we recommend the universal adoption of the Healthy People 2030 definition of health equity: “the attainment of the highest level of health for all people.” This recognizes that achieving health equity requires valuing everyone equally with focused and ongoing societal efforts to address avoidable inequalities, historical and contemporary injustices, and the elimination of health and health care disparities.11 By adopting this definition, we identify a common baseline with an established set of goals and benchmarks. Only with such a common point of reference can we begin to turn to the issue of measurement in a way that better informs our efforts and helps quantify any progress being made in a way that translates across regions, sectors of society, organizations, government agencies, and the entirety of the public health community.

Health equity is more than the absence of disparity: it is “advancing social justice in health.”12 To attain equitable health outcomes universally, we must have an equitable society, and our measures of health equity should reflect the breadth of an individual's or community's social circumstance. The Vital Conditions for Health and Well-Being Framework provides a holistic, inclusive construct in which the broad and disparate components of our lives come together as conditions within which health equity and the promise of thriving for all can be realized.13 The framework articulates 7 conditions that define the elements of a thriving individual or community, including:

Belonging and civic muscle;

Basic health and safety;

A thriving natural world;

Reliable transportation;

Humane housing;

Lifelong learning; and

Meaningful work and wealth.

By focusing on these vital conditions, a picture begins to take shape that shows how the needs of the individual or community form an interconnected web that influences how people and places thrive collectively. An unfulfilled vital condition may compound challenges within 1 or more of the other conditions, negatively affecting outcomes in individual or community health and well-being. Proposed measures of equity should seek to not simply measure the health of the individual or populations of people, which is our legacy approach. Rather, equity should be measured in the status of each of these vital conditions that individuals and community experience. Failure to measure and address these antecedent conditions in a comprehensive way leaves us unclear as to a person's or community's potential for health, well-being, and thriving. Avoiding attention paid to vital conditions also prevents our goal of equity for all from being realized.

Public health in the 21st century, though advanced from that of the mid-19th century of John Snow, finds many of the basic lessons from those early days still hold true. Most prominent among them is the idea that the opportunities that people have—grounded in their communities, the social structures that bind them together, and the environment—are the basis for what makes them healthy. Whether it is John Snow's realization that the water from the Broad Street pump was the source for London's 1854 cholera outbreak, or the current understanding that the disproportionate impacts of COVID-19 have been felt most severely by certain communities or those suffering certain chronic conditions, the social determinants of health—those vital conditions—provide critical context to understand what is demanded for a lasting and equitably healthy public. If the established public health community can work in partnership with all sectors of society and coalesce around a shared understanding of what specifically it is working toward in terms of “health equity”—agreeing to a common definition of “health equity” and a framework within which to measure it—then we will have taken a significant step toward attaining health equity and ensuring enhanced resilience.