Canadian Journal of Public Health (2018) 109:633–642

https://doi.org/10.17269/s41997-018-0128-4

SPECIAL SECTION ON QUALITATIVE RESEARCH

Is ‘health equity’ bad for our health? A qualitative empirical ethics study
of public health policy-makers’ perspectives
Maxwell J. Smith 1 & Alison Thompson 2 & Ross E. G. Upshur 3

Received: 3 February 2018 / Accepted: 23 August 2018 / Published online: 21 November 2018
# The Canadian Public Health Association 2018

Abstract
Objectives ‘Social justice’ and ‘health equity’ are core values in public health. Yet, despite their normative character, the
numerous normative accounts of social justice and equity are rarely acknowledged, meaning that these values are often unac-
companied by an explanation of what they require in practice. The objective of this study was to bridge this normative scholarship
with information about how these ‘core values’ are integrated and interpreted by Canadian public health policy-makers.
Methods Twenty qualitative interviews with public health policy-makers recruited from public health organizations in Canada,
analyzed using an ‘empirical ethics’ methodology that combined empirical data with normative ethical analysis involving
theories of justice.
Findings Participants viewed health equity and social justice as distinct, where the former was perceived as ‘clearer’. Health
equity was conceptualized as focusing attention to ‘proximal’ disparities in access to services and ‘materialistic’ determinants of
health, whereas social justice was conceptualized as focusing on structural issues that lead to disadvantage. Health equity was
characterized as ‘neutral’ and ‘comfortable’, whereas social justice was characterized as ‘political’ and ‘uncomfortable’.
Conclusion These findings indicate that health equity dominates the discursive space wherein justice-based considerations are
brought to bear on public health activities. As a result, ‘uncomfortable’ justice-based considerations of power imbalances and
systematic disadvantage can be eschewed in practice in favour of attending to ‘proximal’ inequities. These findings reveal the
problematic ways in which considerations of justice and equity are, and are not, being taken up in public health policy, which in
turn may have negative implications for the public’s health.

Résumé
Objectifs « La justice sociale » et « l’équité en santé » sont des valeurs fondamentales en santé publique. Pourtant, il est rare que
l’on prenne acte des nombreux exposés sur la justice sociale et l’équité, malgré leur caractère normatif; ces valeurs ne
s’accompagnent souvent d’aucune explication de ce qu’elles exigent en pratique. Le but de notre étude était de combler
l’écart dans la littérature spécialisée avec de l’information sur l’intégration et l’interprétation de ces « valeurs fondamentales »
par les responsables des politiques de santé publique du Canada.
Méthode Vingt entretiens en profondeur avec des responsables des politiques recrutés auprès d’organismes de santé publique du
Canada ont été analysés selon une méthode « empirique éthique » combinant des données empiriques avec une analyze
normative éthique incluant les théories de la justice.
Constatations Les participants considèrent l’équité en santé et la justice sociale comme des notions distinctes, la première
étant perçue comme étant « plus claire ». L’équité en santé est conceptualisée comme mettant l’accent sur les disparités
« proximales » dans l’accès aux services et les déterminants « matérialistes » de la santé, tandis que la justice sociale est
conceptualisée comme mettant l’accent sur les problèmes structurels qui mènent à la défavorisation. L’équité en santé est

* Maxwell J. Smith 1
School of Health Studies, Faculty of Health Sciences, Western
[email protected] University, Arthur and Sonia Labatt Health Sciences Building, Room
331, 1151 Richmond Street, London, ON N6A 5B9, Canada
Alison Thompson 2
Leslie Dan Faculty of Pharmacy, University of Toronto, 144 College
[email protected] Street, Toronto, ON M5S 3M2, Canada
3
Ross E. G. Upshur Dalla Lana School of Public Health, University of Toronto, 155
[email protected] College Street, Toronto, ON M5G 1L4, Canada
634 Can J Public Health (2018) 109:633–642

décrite comme une expression « neutre » et « confortable », et la justice sociale, comme une expression « politisée » et
« inconfortable ».
Conclusion Ces constatations montrent que l’équité en santé domine l’espace du discours où les considérations fondées sur la
justice servent à guider les activités de santé publique. En conséquence, l’examen « inconfortable » des déséquilibres de pouvoir
et des désavantages systémiques, fondés sur la justice, peut dans la pratique être évité en faveur d’un examen des inégalités
« proximales ». Cela révèle des problèmes dans la prise en compte, ou non, de la justice et de l’équité dans les politiques de santé
publique, ce qui en retour peut avoir des conséquences négatives pour la santé publique.

Keywords Health equity . Social justice . Health policy . Bioethics . Public health

Mots-clés Équité en santé . Justice sociale . Politique de santé . Bioéthique . Santé publique

B…the historic dream of public health…is a dream of centrality of these values to the way in which public health
social justice.^ ought to be organized and practiced, it behooves us to under-
stand the sorts of justice-based considerations and demands
– Dan E. Beauchamp (1976) imbued by each value, whether each value instructs us to
pursue distinct justice-related aims, and the degree to which
each value actually informs the work of public health
professionals.
While an emerging body of theoretical literature in the field
Introduction of public health ethics has supplied important insights into
how these values ought to be conceptualized in the public
‘Health equity’ and ‘social justice’ are routinely identified as health context (Daniels 2007; Segall 2009; Powers and
core values in, and for, public health (Beauchamp 1976; Faden 2006; Ruger 2010; Venkatapuram 2011), we believe
Public Health Agency of Canada 2008; Commission on that the task of specifying and clarifying the values that form
Social Determinants of Health 2008). Both values belong to the basis for policy decisions and actions in public health is
the theoretical space of justice. That is, both social justice and both a theoretical and practical endeavour. As such, to com-
health equity are meant to focus our attention to the normative plement an emerging body of theoretical scholarship in this
demands of justice as they relate to the activities of public area, this paper reports findings from a qualitative study that
health policy, practice, and research: whether health benefits sought to understand Canadian public health policy-makers’
are distributed fairly, whether programs adequately respond to perspectives on the meaning and role of social justice in their
the needs of the most disadvantaged, and so forth. That social practice. With the specific aim of illuminating the discursive
justice belongs to this theoretical space requires no further space within which considerations of justice are engaged with
elaboration. For health equity, it suffices to note that health and operationalized in the public health context, this paper
inequities are routinely interpreted as ‘unjust differences in reports findings from this study that concern participants’ per-
health’ (Braveman et al. 2011; Wilson and Inequities 2011; spectives on the relationship between social justice and health
Smith 2015), and so should be understood as relying upon equity and the degree to which each value was perceived as
some notion of justice in order to discern exactly which dif- interacting with their practice.
ferences in health ought to be remediated as a matter of
justice.
This point is worth underscoring because the theoretical
space of justice is vast and diverse; that there are countless Methods
competing accounts of justice contributed from moral and
political philosophy (and elsewhere) suggests that both social This study’s methodology falls within an emerging area of
justice and health equity likely preclude single (or simple) scholarship broadly referred to as ‘empirical ethics’ (Ives
interpretations or applications. Yet, despite the ubiquity and and Draper 2009), and in this case aimed to link empirical
stature of these declared values in organizational mission data generated from key informant interviews with the norma-
statements, ethical frameworks, and in public health scholar- tive ethics debate surrounding the proper aims of social
ship, outside of the theoretical literature the specific justice- justice.
based considerations that ought to be brought to bear on public The manner in which this ‘linking’ occurred could best be
health activities are seldom expounded (Edwards and Davison described as ‘pragmatic’. Like Engel (2009), we take pragma-
2008; Trotter 2008; Fafard 2012). Given the putative tism to be the view that “epistemic reasons and
Can J Public Health (2018) 109:633–642 635

justifications—such as our reasons for taking a belief to be the theories of Daniels (2007), Ruger (2010), Venkatapuram
true or well confirmed—are either determined or can be over- (2011), and Segall (2009), in addition to the broader theoret-
ridden by practical or prudential reasons or justifications” (p. ical landscape of social justice (i.e., theories developed with-
185). As such, this study did not seek to discover some uni- out a particular focus on, or concern with, health, and public
versal and unwavering ‘truth’ about what social justice is, nor health), were also integral. While present space does not per-
was it seeking to validate normative theory or simply describe mit a discussion of these contributions and the salient differ-
perspectives on social justice. What it ultimately aimed to do ences between them, something brief will be said here to char-
was generate empirical information about public health poli- acterize the conceptual landscape of justice for those less fa-
cy-makers’ perspectives on social justice, and, in light of this miliar with the topic.
information, explore the practical or prudential reasons and Justice consists of the apportionment of benefits and bur-
justifications—derived from both theory and interviews—that dens, advantages, and disadvantages, to individuals in accor-
might exist in supporting the further exploration of particular dance with that to which they have a moral claim. As such, the
considerations of social justice in public health, or in advocat- pertinent task for justice is to say something about the sorts of
ing for the modification of how social justice is conceptualized moral claims that people have as a matter of justice, in addi-
and pursued in practice. tion to the manner in which competing claims ought to be
To accomplish this pragmatic aim, this study sought to evaluated and acted upon.2
establish a contextual understanding of the ways in which Generally speaking, justice is often characterized as having
social justice is discussed in the practice of public health, distributive, procedural, and/or relational dimensions. 3
including how the term is interpreted and used at ‘ground Distributive justice applies criteria of justice to the distribution
level’ (Ives and Draper 2009). This was imperative because of certain goods. Substantial debate exists concerning the sorts
ethical concepts like social justice and health equity are not of goods whose distribution ought to be of concern to us as a
simply superimposed onto a field like public health, and they matter of justice (Cohen 1990). Traditionally, and particularly
typically do not logically entail specific policy directions or in the health context, these typically include access to services
responses (Giacomini et al. 2009; Jennings 2015). Rather, (e.g., immunization clinics), resources (e.g., health care re-
when values like social justice are interpreted and discussed sources; income), opportunities or capabilities to be healthy,
in the context of public health policy and practice, the mean- and health outcomes themselves.4 Debate also exists regard-
ings of these values are “transformed and contextualized or ing the criteria of justice used to prescribe the pattern or basis
localized” (p. 9) (Jennings 2015). This study therefore aimed of distribution for any particular good, where typical candidate
to situate theory and, ultimately, the ‘pursuit of social justice’, principles include equality, sufficiency, and priority (Ruger
in practice1; instead of normative theory underlying practice, 2010). Multiple principles and currencies of justice mean that
this study sought to locate and understand theory within prac- numerous permutations are reflected in competing accounts of
tice (Ives and Draper 2009). justice; one may defend the view that justice demands the
equal distribution of the resources viewed as being necessary
Normative theory to bring about health, that access to services be allocated with
priority given to the least healthy, that policies and practices
This study’s theoretical background and interpretive apparatus are organized to best ensure individuals reach a sufficient level
for data analysis comprised multiple theories of justice that of health, and so forth.
were themselves developed out of a particular concern with Procedural justice, on the other hand, consists of applying
questions of social justice in public health. While Powers and criteria of justice to processes rather than directly to actual
Faden’s Twin Aim theory of social justice (Powers and Faden distributions or outcomes (Daniels 2007). Hence, procedural
2006) served as a focal point given the authors’ unique claim justice may demand that public health decision-making accord
that it “offers a moral foundation for the theory and practice of with principles such as consistency, inclusiveness, and/or
public health” (p. 156) (Faden and Powers 2008), and that it transparency.
“provides a fine, if not perfect, fit with the commitments and
2
practice of public health” (p. 80) (Powers and Faden 2006), One cannot do justice to the vast conceptual and theoretical landscape of
justice in such little space, and so this brief characterization is necessarily an
oversimplification.
1 3
This pragmatic aim is consonant with, and is grounded in, our epistemolog- As Jost and Kay (2010) note, it can be useful to distinguish between these
ical views, which tend toward critical realism. On this account, because knowl- dimensions of justice, but “little is gained by exaggerating or reifying such
edge is considered to be fallible and theory-laden (but not entirely theory- divisions” [p. 1143]. A theory of justice may address any or all of these
dependent), we believe that the data generated in this study cannot be detached aspects.
4
from theory; what ‘counted’ as data at least to some extent was determined in The act of specifying the currency of justice is itself a normative task, and as
light of the interpretive apparatus used in this study, which neatly aligns with such, different accounts of justice invariably concern themselves with different
our interest in linking the empirical data generated in this study with the goods according to the moral significance bestowed to such goods and the
normative debate surrounding the proper aims of social justice. perceived capacities of social institutions to influence their distribution.
636 Can J Public Health (2018) 109:633–642

Relational justice requires a disposition to treat individuals Participants and setting

in accordance with principles that express just relations. Only
when principles of just relations are satisfied (e.g., when indi- Because public health in Canada is the shared responsibility of
viduals are treated with equality of standing or status) can the governments at the municipal, provincial/territorial, and fed-
distributions resulting from those relations (e.g., of health) be eral levels, this study did not set out to restrict the involvement
considered just. Respect, power, privilege, and responsibility of participants to any one of these levels. However, due to
have all been proposed as being central to relational justice, reasons of feasibility, participants were recruited from only
shifting the attention of distributive justice towards the critical one municipal level (public health units within the Greater
investigation of social phenomena like domination, subordi- Toronto Area) and from only one provincial level (public
nation, exploitation, oppression, and marginalization (Miller health departments or agencies at the provincial level in
2001; Jost and Kay 2010; Young 1990). Ontario, which were also located in the Greater Toronto
Finally, equity itself is often construed as a material Area), in addition to recruiting participants from the federal
principle of justice, which in the health context could be level in Canada (who were located in Ottawa).
understood as concerning itself with the ratio of one’s Key informants were recruited purposively based on their
health needs to one’s receipts (e.g., of health services); professional positions in order to permit in-depth inquiry into
justice exists when this ratio is equal for all individuals. individual perspectives on the topic of interest and from the
However, it is perhaps more typical in this context for population of interest (Patton 2001). The key informants
equity to be understood in terms of inequity, which is sought for recruitment were characterized as public health
commonly understood as referring to an ‘unjust differ- ‘policy-makers’. ‘Policy-maker’ in this study refers not to a
ence in health’ (Braveman et al. 2011; Wilson and precisely defined, homogenous set of individuals who have
Inequities 2011; Smith 2015). As previously mentioned, this title, but rather to a population of interest to this study
this means that health equity ultimately relies upon given their role in developing or implementing policy and
some notion of justice in order to discern exactly which practice change in public health organizations or agencies.
differences in health ought to be remediated as a matter Key informants therefore included policy advisors, policy-
of justice. level decision-makers, and other individuals involved in drafting
policy briefs or scientific guidance aimed at shaping policy.
A second aim of this study, the findings of which will be
Data collection reported elsewhere, was interested in exploring and examining
the extent to which the perspectives of public health policy-
Despite frequent calls to use qualitative methods in social justice makers involved in different programmatic areas of public
research (Sabbagh and Golden 2007; Giacomini et al. 2014), health were similar or different. As such, participants were
there is a paucity of qualitative research exploring perspectives recruited from two well-established programmatic areas, or
on social justice. This study employed a qualitative design, where ‘contexts’, of public health: chronic disease prevention and
data were generated through open-ended, semi-structured inter- public health emergency preparedness and response.
views. The interview guide was developed according to the aims Government directories and websites were primarily used to
and structure of what Brinkmann and Kvale characterize as a identify potential participants (e.g., Government Electronic
‘conceptual interview’, which seeks to explore meanings and Directory Services (GEDS)). Once local contacts were identi-
conceptual dimensions of central terms, and ‘chart’ participants’ fied, snowball sampling was used to identify additional poten-
conceptions of phenomena, like social justice and health equity tial participants involved in policy and practice change in the
(Brinkmann and Kvale 2015). The interview guide incorporated public health area of interest.
questions that explicitly inquired about participants’ perspectives Twenty interviews were conducted in total, with ten partic-
on the meaning and role of social justice in the context of their ipants practicing in the area of chronic disease prevention
practice, as well as questions that asked participants to speak (three at the federal level, three at the provincial level, and
freely in voicing their opinions, values, and judgements about four at the municipal level) and ten participants from the area
the goals and scope of their domain of public health practice in of public health emergency preparedness and response (three
order to explore participants’ ‘interpretive processes’ (Patton at the federal level, four at the provincial level, and three at the
2001). municipal level). The interviews ranged from 30 to 80 minutes
Interviews were conducted between March, 2014 and in length, with an average and median interview length of
January, 2015. Recruitment of participants ceased when the- 60 minutes. Each interview was conducted either in person
matic saturation was reached within the data; that is, when or over the telephone by the first author. Interviews were audio
new data no longer shed any further light on the issue under recorded and were transcribed verbatim by a professional
investigation (Sandelowski 1995). qualitative research transcriptionist, which were then verified
by the first author by reading the transcript while listening to
Can J Public Health (2018) 109:633–642 637

the associated audio file. This study received formal ethics Findings
approval from the Office of Research Ethics at the
University of Toronto and all participants provided written The two themes presented here speak to the ways in which
consent prior to participation. study participants talked about social justice and health equity
and shed light on the discursive role that different justice-
based considerations played as situated within the partici-
Data analysis pants’ context of public health practice.5

The process by which data were analyzed aligns most closely

with Braun and Clarke’s method of ‘thematic analysis’, which The relative clarity and prominence of health equity
is a method for identifying, analyzing, and reporting patterns
or themes within data (Braun and Clarke 2006). Data analysis Participants raised the term ‘equity’ throughout interviews,
began by reading and re-reading each transcript to get a sense even in direct response to questions about social justice, which
of the data corpus. Following this stage, initial codes were suggests that they perceived there to be a relationship between
generated for each interview. The generation of codes was the two. When probed about this, participants expressed that
largely data-driven and was conducted with the aim of char- they felt the meaning of health equity is ‘clearer’ than social
acterizing the words and ideas used in the data as descriptively justice:
as possible. Data management was facilitated by NVivo qual-
itative data management and analysis software.
Similar codes and similarly coded extracts were then col- “I’d say equity, you know, the answer to your question is
lated in order to explore and identify potential themes within that equity is clear to me. Social justice, I think the
the data. Themes were actively identified if they captured definitions are fuzzy.” (P03-PHEPR-P)
something important or of interest in relation to this study’s
research questions and theoretical background (theories of The general lack of clarity participants expressed regarding
social justice) (Braun and Clarke 2006). Themes were there- the meaning of social justice made more sense to us once
fore constructed both inductively based on the descriptive participants made it evident that social justice is generally
codes, allowing analysis dimensions to ‘emerge’ from codes not perceived to be explicitly part of the discourse of their
identified in the data, and deductively, based on the study’s daily work in public health:
interpretive apparatus. The generation of themes was
achieved, in part, by conducting a ‘theoretical reading’ of
transcripts and codes (Brinkmann and Kvale 2015). This “We talk about equity but we don’t, we, we don’t talk
meant that this study’s theoretical background ‘sensitized’ about social justice.” (P04-PHEPR-P)
the analysis, suggesting ‘directions in which to look’ (which “I don’t hear the term social justice, um, that specific
can be contrasted with the theoretical background being ‘de- term, what I am hearing more and more is that talking
finitive’, which ‘defines what there is to see’) (Brinkmann and about, um, health inequalities and health inequities.”
Kvale 2015). At all phases of analysis, detailed notes were (P16-CDP-M)
kept that identified which codes were added, removed, or
collapsed, in order to establish an ‘audit trail’ (Lincoln and This had implications for how the subject matter was
Guba 1985). discussed in the remainder of each interview. For instance,
when participants were asked to recall something in their pub-
lic health work that they would consider to be ‘unjust’, or
5
In the description of themes, data extracts are presented in order to illustrate
perhaps something that, to them, reflected an attempt to
the ways in which themes are supported by the data. Extracts were chosen ‘achieve’ social justice, participants provided responses but
according to their ‘aptness’ in illustrating the nature of the theme discussed. often reverted to speaking about inequities and equity without
Each extract includes an identifier, which acts to contextualize the quote: the
addressing the fact that the question was about social justice.
first three characters (e.g., ‘P08’) refer to the participants’ numerical identifier
(e.g., participant number eight), the second set of characters (either ‘CDP’ or Overall, participants generally appeared to have a greater
‘PHEPR’) indicate the programmatic area of public health practice coded for comfort in speaking in terms of equity and inequities rather
the participant (chronic disease prevention or public health emergency pre-
than social justice and injustice. As will be illustrated in the
paredness and response, respectively), and the third set of characters (‘M’, ‘P’,
or ‘F’) indicate the level at which they worked (municipal, provincial, or next theme, though, while these findings support the idea that
federal, respectively). In some instances, data extracts are presented that in- participants considered social justice and equity to have a
clude not just quotes from participants but also include the interviewer’s inter- close relationship, when prompted, they believed the two
action with participants. In these instances, participants’ voices are prefaced by
a ‘P’ at the beginning of quotes (to represent ‘participant’), and the inter- values evoked considerations of different kinds and used dif-
viewer’s voice is prefaced by an ‘I’ (to represent ‘interviewer’). ferent words and ideas when discussing each concept.
638 Can J Public Health (2018) 109:633–642

Health equity as a ‘safe’ alternative to social justice P: “But I think a lot of it is...like, we can all agree to the
principles. Most of us anyway. We do have an econo-
Participants spent considerable time discussing the distinction mist in our midst, which is an interesting, always an
between health equity and social justice, what each term interesting perspective. But, I think where people get
meant to them, and the role each idea plays in their work. stuck is that there isn’t a very good understanding, at
Participants used words like ‘proximal’, ‘neutral’, and ‘quan- least within [the public health organization], it’s not top
tifiable’ to describe health equity: of mind as to why you have differences in outcomes
according to income, or according to ethnicity, or things
like that.”
“It [equity] feels more proximal. It feels more neutral. It I: “And that why matters?”
feels more, uh, quantit-, uh, quantifiable, okay? P: “And the why is key to the whole thing. In a
Whereas getting, moving from the discussion about deeper...in a deeper way.” (P13-CDP-P)
health equity to unfair and unjust to talking about jus-
tice, to talking about social justice, requires that personal For participants, these distinct foci of health equity and
confrontation and unpacking about what are my biases, social justice have practical implications. For instance, partic-
what am I not comfortable with, how do I feel about ipants suggested that health equity focuses attention, and ulti-
certain things, that some people don’t have the time or mately flavours the scope of ‘inequities’, towards ‘superfi-
the inclination to do, okay? So that’s where I think the cial’, ‘materialistic’ things rather than the ‘deeply embedded’
conversation needs to deepen on the difference between challenges that are more situated within the domain of social
health equity and social justice.” (P07-CDP-P) justice:
“For some reason equity to me seems almost [long
pause] a little bit more, uh, objective or quantifiable, or
more easily described, whereas social justice, to me, is, P: “[Sarcastically asking] Why do we have to focus on,
is a much broader, softer concept, um, but more all- you know, STI incidents in gay men, because they have
encompassing.” (P14-PHEPR-F) got really high income? Okay? So this is, like, exactly
the sort of the, the, the immediate reaction is, it’s [health
Participants contrasted the ‘comfortable’, ‘quantifiable’, equity] about income. It’s a materialistic interpretation
‘proximal’ nature of health equity with social justice, which of inequity rather than an understanding of sort of deep-
was characterized as concerning ‘-isms’ (e.g., ‘racism’, ‘sex- ly embedded, um, sort of cultural or structural or other
ism’, ‘colonialism’) and ‘deeper’ ‘political’ and ‘structural’ kinds of norms.”
issues. Participants indicated that discussing social justice I: “Do you think that, the deeply embedded in the
would take their work in a very different direction than health ‘-isms’ like you talk about, is that more the domain of
equity: social justice?”
P: “Yes, yes, and that’s where, that’s why I think
that it’s almost easier to talk about health equity.”
“What’s the social justice impact of housing policy, of (P07-CDP-P)
daycare policy? Let me tell you, that will, that will take
the conversation in a, in a different direction, I believe, “A health equity impact assessment is, is more comfort-
in a deeper, richer direction, than just, uh, and I don’t able for people because it’s most likely going to focus on
mean just, but, than simply talking about health equity the materialistic kind of determinants and the, and the
or inequity.” (P17-CDP-M) view of health equity, a materialistic view of health eq-
“They [a public health organization] noted that they uity…They [‘most people’] totally think about health
have this big gap in their services around Aboriginal equity around disability access, basically, like ramps. It
clients and they specifically did something about it. Is comes up more than you might expect…around the ma-
that improving health equity? Maybe, maybe, but it just terialistic perspective of equity where it’s all about in-
goes right back to wondering, well, what exactly is come and education, and it’s not about like racism and
health equity? Does that make any difference to social gendered stuff and, you know, more [Long pause]
justice? I don’t think so. Because the structural things harder to get your head around that concept.” (P10-
you haven’t changed at all.” (P10-CDP-P) CDP-P)

These distinguishing considerations of social justice were This ‘superficial’ focus of health equity was reflected in
often characterized as a concern for the ‘why’: participants’ discussions of the way in which health equity
Can J Public Health (2018) 109:633–642 639

considerations interact with or are implemented through pub- Interestingly, one participant characterized the sorts of con-
lic health activities: at the level of public health programming. siderations imbued by health equity as ‘safe’, which renders
them easier to discuss in practice, whereas other ‘social jus-
tice’ considerations are too divisive to be discussed:
“I think public health can point out challenges
related to social justice, but I am not sure it can
actually solve them. Whereas public health is in a “Talk about racism in here? Are you kidding? …
position to deal with equity in terms of access.” Institutional racism leads to people not going to the doc-
(P03-PHEPR-P) tor. You know? And so, these things are very real, too,
“Many people understand health equity in terms of and to me that’s social justice, right? But, not in here.”
equal access to services, that understanding is like, or (P13-CDP-P)
they might say equitable access to services. So it’s
services, access…That’s where the conversation moves With all of that said, several participants acknowledged
to being about health equity to about social justice, that, despite the importance of social justice considerations
okay? That’s the neat thing for me, when it gets to there. in public health, the considerations discussed above falling
Whereas I think when we talk about health equity we’re under the rubric of health equity may be ‘better than nothing’:
often talking about, you know, a very shallow thinking
about access to resources, access to health care.” (P07-
CDP-P) “If people don’t want, you know, like, uh, the collective
consciousness…isn’t ready for social justice, then let’s
This focus on public health programming can be just take health equity if that’s all we can get, right?”
contrasted with where it is that participants considered (P10-CDP-P)
the primary focus of social justice considerations to be, “Ultimately you have to go there [engage with social
which was characterized as being in the realm of the justice considerations], but, I think that health equity
‘political’. In this context, participants discussed the as- becomes a transition point for getting into that, so it’s
sociated constraints related to thinking about social really around how do you take it further?” (P07-CDP-P)
justice:

“I see social justice certainly as the, the political piece of Discussion

equity, and that’s perhaps just my interpretation, but I
look at social justice more in terms of that piece and I These findings say a number of important things about the
look at equity much along the things of, so, what’s eq- tenor and scope of the discursive space wherein considerations
uitable in terms of programs and services, more of the of justice are raised in, and ostensibly brought to bear on,
softer side.” (P18-CDP-M) public health policy and practice.
“We don’t want to, if we wanted to turn our whole so- While both health equity and social justice are situated
ciety upside down and hand all the power over within the theoretical space of justice, this study’s findings
[Laughter], I don’t think that’s going to happen, but that, are particularly illuminating because they indicate that partic-
in that, that’s where social justice starts to go, right? ipants attributed particular (though not necessarily uniform)
Which is where health equity is much more comfortable justice-based considerations and characteristics to each of
because it’s like, it’s like just about health, it’s like, I can these two values. Whereas participants described health equity
keep my power but I want to reduce your diabetes, with words like ‘proximal’, ‘objective’, ‘neutral’, ‘comfort-
right? And, and I am okay with that.” (P10-CDP-P) able’, and ‘quantifiable’, social justice was described with
words like ‘political’, ‘structural’, ‘subjective’, ‘qualitative’,
The foregoing extracts allude to the putatively divisive na- ‘deeply embedded’, and ‘all-encompassing’. Social justice
ture of social justice, which is contrasted with the ‘neutral’, was also described as possessing a salient evaluative (i.e.,
‘comfortable’ nature of health equity. Some participants sug- normative) component. Health equity, on the other hand,
gested that health equity is an ‘easier’ way in which to discuss was described as having a ‘neutral’ and ‘objective’ quality,
these justice-based considerations: and as focusing on or attending to the ‘proximal’—access to
public health resources and services and the distribution of
‘materialistic determinants’ (i.e., things amenable to distribu-
“Health equity for us is a lot easier to sell.” (P18-CDP- tion) like income. As such, health equity appears to operate
M) rather squarely within the distributive paradigm, whereas
640 Can J Public Health (2018) 109:633–642

social justice seems more likely to invoke considerations of social justice as ‘out of bounds’ or simply not ‘actionable’
relational justice. given a lack of institutional mechanisms (or appetite) to pur-
The upshot of this is that these findings suggest that social sue such concerns. As such, oppressive forces like racism
justice and health equity are ‘used’ to point to different justice- should be viewed as manifesting institutionally in such a
related considerations, which emphasizes the importance of way that simultaneously disadvantages individuals in the pro-
examining the role each value plays in practice. These find- vision of services (e.g., “Institutional racism leads to people
ings indicate that participants were more comfortable speak- not going to the doctor”) as well as by precluding policy-level
ing about health equity, that they perceived health equity as discussion and intervention (e.g., “Talk about racism in here?
having a ‘clearer’ meaning, and that discussions of health Are you kidding?). It also highlights the fact that those sub-
equity were perceived to be more common than were discus- jected to systematic disadvantage—those who may be far
sions of social justice. For these reasons, we interpret these more comfortable confronting systems of inequality given
findings as suggesting that health equity dominates the discur- their proximity to them—are less likely to occupy such posi-
sive space wherein considerations of justice are expressed tions in the first place. As such, the discursive space wherein
among public health policy-makers. As a result, these findings considerations and concerns of justice can be raised in practice
suggest that the justice-based considerations that are discussed may in turn be circumscribed to that which is viewed as ‘safe’
and ostensibly brought to bear on public health activities may by those who ultimately have the opportunity to occupy such
be those tending to be imbued by the concept of health equity. positions. The upshot is that the ‘safe’ alternative that health
The idea that health equity dominates this discursive space equity offers may be decidedly ‘unsafe’ for those subjected to
is further supported by examining participants’ perspectives the greatest inequities. Failing to confront uncomfortable,
on the relative ‘ease’ with which health equity and its partic- structural injustices may therefore render work in ‘health eq-
ular considerations can be ‘used’ in comparison to social jus- uity’ complicit in perpetuating such inequities.
tice. Participants perceived health equity as ‘easier to sell’, These findings and interpretations significantly nuance the
‘simplifying our lives’, and ‘safe’, whereas social justice was current understanding of the relationship between health equity
described as being ‘really difficult’ and subject to ‘political and social justice that exists in the empirical literature. This
sensitivities’, eliciting ‘very strong reactions’ and requiring a literature reports that social justice is commonly perceived to
personal confrontation of biases and privilege that many are be important, or in some way linked, to health equity (though
likely to resist. In other words, these findings indicate not only this conceptual relationship has not been previously explored
that participants perceived discussions of health equity to be empirically). For instance, Rizzi reports that, for the frontline
more common than social justice, but also that particular ob- public health practitioners who participated in her Ontario-based
stacles were perceived to exist that prevent or preclude discus- study, the “theme of fairness was [a] dominant [frontline staff]
sions of social justice (and the considerations imbued by the descriptor of health equity, and [was] often made in reference to
value) from occurring. The prominence of health equity in the the concept of social justice” (p. 47) (Rizzi 2014). In addition,
space wherein justice-based considerations are discussed may Knight states that, in her study, “[p]articipants described the role
stem from the fact that the concept operates in such a way that of the field in addressing health inequities as being grounded in
allows one to raise and apply putatively ‘neutral’, ‘objective’, the evidence base, as well as in the value of social justice, which
and ‘proximal’ justice-based considerations without wading they believed were mutually reinforcing. Recognizing that social
into the divisive, normative, and uncomfortable territory of justice underlies health equity requires strong engagement with
social justice. It facilitates the consideration of justice in rela- the political process” (p. 192) (Knight 2014). Thus, on the basis
tion to public health activities without asking ‘deeper’ ques- of the existing empirical literature alone, one might simply infer
tions about the social forces contributing to why health ineq- that health equity and social justice are somehow mutually rein-
uities exist, without confronting ‘deeply embedded structural forcing in practice; that health equity is imbued with consider-
or cultural norms’, and without ‘handing over power’. This ations of social justice, and so when health equity is invoked it
may reflect a broader trend in public health which favours a ‘brings along’ social justice considerations and therefore helps to
reductionist thinking that tends to insufficiently engage with advance social justice aims.
social parameters and theories (Krieger 2013). Our data echo Knight’s finding in particular given that our
Moreover, Participant 7’s reflection—that moving from participants similarly expressed that social justice concerns the
health equity to social justice requires confronting and political process and underlies health equity. However, our
unpacking personal biases and areas of discomfort—signals findings refine this understanding by indicating that the per-
the important role that social location plays in relation to the ceived link between social justice and health equity does not
‘ease’ with which certain questions or concerns of justice may necessarily equate to the fact that social justice considerations
be raised or addressed by policy-makers. These sentiments will be systematically considered or addressed when health
speak to the pervasive ways in which systems of inequality equity is invoked. To the contrary, our findings suggest that
might manifest institutionally, which can render discussions of health equity may actually provide a way in which to discuss
Can J Public Health (2018) 109:633–642 641

justice-based considerations without engaging with the con- Operationalizing justice-based considerations solely
tentious subject matter of social justice, including the ‘political through the remediation of ‘inequitable’ access to services
piece’ (or at the very least may provide a way to do so that and resources will fail to adequately address (or take into
takes these social justice considerations for granted). account) unfair social arrangements that may prevent individ-
‘Uncomfortable’ justice-based considerations of structural uals or populations from realistically improving their pros-
‘-isms’, power imbalances, and systematic disadvantage can pects for well-being and exiting a state of affairs where they
be eschewed (or simply taken for granted) in favour of attend- are constantly at risk of decline. And, by not sufficiently en-
ing to ‘proximal’ inequities. Engaging with divisive, political gaging with social forces like racism, sexism, and colonialism,
considerations is avoided by appealing to a concept that is one will also fail to address intersectional forces that com-
putatively objective and neutral. The latter becomes ‘easier to pound disadvantage. By failing to engage with the social
talk about’, ‘easier to sell’, and ‘safe’, and for some may alto- mechanisms through which disadvantage, and conversely, ad-
gether obviate their perceived need (or appetite) to engage with vantage, are perpetuated and exacerbated—phenomena
the more challenging social justice considerations (e.g., “let’s Powers and Faden refer to as ‘densely woven, systematic pat-
just take health equity if that’s all we can get” (P10-CDP-P)). terns of disadvantage’(Powers and Faden 2006)—one will not
While there is nothing inherently problematic with attend- only neglect a principal concern of justice, but will also likely
ing to questions of justice that attach to issues of access to fail to meaningfully redress inequities in deprivation that stem
resources and services, we will conclude by outlining two from disproportionate access to health services.
reasons why it ought to be viewed as concerning. First, it is Second, by severing a connection between the sorts of jus-
concerning if this altogether supplants attention towards other tice-based considerations imbued by health equity and those
considerations of justice, and especially those that concern imbued by social justice, it may be that the underlying norma-
upstream injustices that ultimately sustain or exacerbate issues tive assumptions and commitments of health equity can more
of access to public health resources and services (i.e., to ‘struc- readily be taken for granted. If addressing inequitable access
tural’ determinants of health). Indeed, attending to issues of to public health services is perceived as ‘neutral’ or ‘objec-
access alone fails to address other key aims widely considered tive’—that is, if it is not in some way linked to the normative
to be important to justice, including the correction of “patterns concern of injustice—then one may end up addressing those
of systemic injustice among different groups, seeking to im- ‘inequities’ that are easiest to remediate, addressing those that
prove rather than worsen systematic disadvantages in society” may be far down on the list of inequities that ought to be
(p. 10) (Kenny et al. 2010). What we are left with, then, is a remediated, or addressing those that may not actually be im-
concept of equity that is detached from structural and societal portant to remediate as a matter of justice. In this form, health
considerations of social justice—considerations that are of equity loses its critical capacity and establishes a path of least
central importance to nearly every account of social justice resistance to assessing and incorporating justice-based con-
developed in the public health context (Daniels 2007; cerns and considerations in public health. While there is no
Powers and Faden 2006; Venkatapuram 2011). doubt that ‘equity in health’ is critical and ought to be priori-
Remediating ‘inequities’ in terms of access to public health tized in public health, these study’s findings reveal the prob-
services and resources is no doubt an important aim of justice. lematic ways in which considerations of justice and equity are,
This aim recognizes that an injustice obtains when individuals and are not, being taken up in public health, which may be bad
or populations are deprived of particular benefits given their for the public’s health.
unequal access to those benefits. This is reflected in the first
aim of Powers and Faden’s theory of justice, for instance, Compliance with ethical standards
which seeks to combat deprivation in well-being (Powers
and Faden 2006). Injustice is located in the adverse conse- This study received formal ethics approval from the Office of Research
Ethics at the University of Toronto and all participants provided written
quences for well-being that may obtain from inadequate ac-
consent prior to participation.
cess to important public health services and resources, and so
addressing concerns of access works to remediate depriva- Publisher’s Note Springer Nature remains neutral with regard to juris-
tions in well-being. However, this may do little, if anything, dictional claims in published maps and institutional affiliations.
to combat the ‘enemy’ of the other aim of Powers and Faden’s
theory, which is disadvantage. This second aim of justice
concerns structural fairness, which locates injustice in the
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