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Health Equity Lens
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The Stream Parable
The Modern Stream Parable
Values and Assumptions
The Stream Parable
There is an old parable often told in public health about people falling in a stream, which is a metaphor for getting sick. Although there are many versions told, the story typically highlights the difference between efforts to rescue individuals from drowning in the water (i.e. medical treatment) and efforts to keep them from falling in farther upstream (i.e. prevention).
(Click the image shown left for one version of the story.)
This parable is frequently recited to illustrate a major contributor to the current health crisis in the United States. That is, funds are generally being directed towards costly procedures and treatments of specific diseases rather than towards upstream preventive approaches like community-based interventions, population-based approaches, and policy changes that create healthy environments.
While this is true, something is still missing from this story…
The Modern Stream Parable
The traditional parable is useful in highlighting the need for more prevention. However, we know that certain groups of people are more likely to fall into the river than others. They do not fall in because of individual weakness or intrinsic flaws. They are more likely to get sick because of underlying, systemic, and structural social and economic inequities.
We've developed a slightly different version of the parable that tells a more complete story. (shown right)
The health equity guide is grounded in the knowledge that some people are privileged to live in communities with strong bridges, usually made of high quality materials that protect them from falling into the river and promote their safe passage across. Members of other groups, often characterized by gender, race, socioeconomic status, sexual orientation, gender identity, age, or disability status, are more likely to live in communities with poorer quality bridges.
Yes, we need to move upstream to prevent people from falling in, instead of directing the majority of our efforts to pulling people out. However, we also need to ensure that all of our communities have strong bridges such as clean air and safe drinking water, quality and affordable housing, living wage jobs, green space and safe areas for children to play, as well as social justice and power in decisions that affect those communities.
Our approach to the development of a health equity strategy is premised on a range of values and assumptions that permeate the health equity debate in the United States and across the world.
Our views reflect the assumption that moving upstream to mend bridges and build fences is likely to be more effective in promoting health and reducing health inequities.
An upstream approach may be considered more ethical because it prevents pain and suffering for the population as a whole, while at the same time, reduces gaps in morbidity and mortality between groups. However, opportunities also exist within the health care system to make the delivery of care more equitable. Such changes can contribute to advancing health equity by ensuring access to quality health care for everyone. Reflecting again on the stream parable, this means that everyone has the opportunity to receive quality care, should they fall in the river and become ill. For this reason, the toolbox developed by our team prioritizes activities in the social and physical environment, including within the health care system.
Our view is that effective action to eliminate health inequities must be grounded in principles of social justice, which includes attention to social and economic equality and a fair distribution of advantages, as well as a stronger democracy where individuals have greater control over decisions that affect SDOH.
Achieving health equity will ultimately require us to confront deeply entrenched values and cultural norms. Referring to the stream parable, this means that we have to do even more than ensure everyone has the opportunity to cross the strong bridge or live near the quality fence. It means that all communities along the stream have the power to make decisions and have control over resources to build their bridges and fences the way they believe they should be built.
Changing the power dynamic in our communities means that some will have to relinquish power as others become more empowered. This complicated (and uncomfortable) conversation about class and power is beyond the scope of our equity guide, as it requires major social and political changes. Still, it is easy for these important issues to be obscured by a focus on more intermediate kinds of change recommended in the health equity guide.
“There has to be public recognition of the real sources of health inequities… we have to understand that class and class exploitation, racism, sexism, and imbalances in power that create those phenomena are the basic source of health inequities." (Knight, 2014)
Values & Assumptions
We recommend that collaborative community efforts aimed at advancing health equity begin with a discussion of these assumptions to ensure that participants understand their meaning and implications and are adopted as shared principles (or adapted accordingly):
1. Health is broadly defined as a positive state of physical,
mental, and social well-being and not merely the absence of
2. Everyone—regardless of race, religion, political belief, and
economic or social condition—has the right to a standard of
living adequate for health, including food, clothing, housing,
medical care, and necessary social services.
3. Health is more than an end. It is also an asset or resource
necessary for human development and well-functioning
4. Health is socially and politically defined. Individual and
medical definitions of health ignore important interactions
between individual factors and social and environmental
5. Health is a collective public good, which is actively produced
by institutions and social policies.
6. Equity in health benefits everyone because health is a public
good necessary for a well-functioning society.
7. Inequities in population health outcomes are primarily the
result of social and political injustice, not lifestyles,
behaviors, or genes.
8. An accumulation of negative social conditions and a lack of
fundamental resources contribute to health inequities, and
include: economic and social insecurity; racial and gender
inequality; lack of participation and influence in society;
unfavorable housing; unhealthy conditions in the workplace
and lack of control over the work process; toxic
environments; and inequitable distribution of resources
from public spending.
9. Tackling health inequities effectively will require an emphasis
on root causes and social injustice, the latter concerning
inequality and hierarchical divisions within the population.
Items 1 and 2 are adapted from the Constitution of the World Health Organization (1946) and the Universal Declaration of Human Rights (1948). Items 3-9 are adapted from Hofrichter, R. & Bhatia, R. (Eds.). (2011). Tackling health inequities through public health practice: Theory to action (2nd ed). New York: Oxford University Press, p. 6.