Health Equity in One Health

Maya Gislason and Craig Stephen

The World Health Organization’s (WHO) 1986 Ottawa Charter for Health Promotion acknowledges the inseparable links between people and their environments. Reciprocal care occurs when we take care of each other, our communities, and our natural environment to create and sustain social and ecological options to reduce vulnerability, avoid unintended consequences, and promote resilience. A reciprocal care approach enables humans and animals to reach their full health potential. It strives to ensure that efforts to protect the health of individuals in one species, and in one generation, do not disadvantage, threaten, or lead to the extinction of other species and generations. Humanity is free to pursue long-term social and economic development if that pursuit is sustainable and developed through practices which do not fracture reciprocal care by depleting ecological services, generating great social injustices, or crossing critical thresholds for essential planetary processes. Reciprocal care requires us to strive for interspecies and intergenerational health equity.

Health equity exists when there is fair access to the resources and opportunities needed for health. Equity is a notion rooted in the principle of justice and fairness and has been enshrined in law in the Western world for over seven centuries (Holdsworth, 1914). While a widely embraced moral principle, equity is a complex idea to coherently embody in health practice, advance in policy, and robustly manifest as a society. Health equity is concerned with socially produced advantages or disadvantages that are not the result of natural biological differences yet affect the distribution of health resources and outcomes. Health equity is a term that has been almost exclusively used in reference to human health. However, at

BOX 3.1 INEQUITY VERSUS INEQUALITY Inequality and inequity sound similar but mean different things.

Inequality: This refers to the uneven distribution of health or health resources as a result of genetic or other factors or the lack of resources.

Inequity: This refers to unfair, avoidable differences arising from poor governance, corruption, or exclusion.

its root, equity calls for all beings to be able to access what they need not only to survive but also to thrive.

The capacity to cope with the challenges of life is not distributed evenly between individuals, populations, species, or ecosystems. Inequalities in health are a fact of life. Ecological competition, the struggle between two organisms for the same resources within an environment, describes differences in capacity that ultimately advantages certain individuals or species over others, leading to differences in opportunities, health outcomes, and ultimately survival. Examples of inequalities can be seen in agriculture where some breeds of domestic animals fare better than others under modern farming conditions as well as in nature where, for example, some species have innate genetic traits that make them more adaptable to varying environmental conditions than others. Inequalities in health outcomes can be seen in different groups of the same species, depending on how they are managed. For example, the causes of death, longevity, and productivity are measurably different between subpopulations of the highly endangered Vancouver Island marmot. The patterns of diseases and causes of death in marmots born in the w'ild differ from those born in captivity, which differ from those released to the wild after captive rearing (McAdie, 2018). The simple passing of time can create inequalities. The health status of an octogenarian, for example, will be different than that of a teenager. Variations in biological endowment, environmental quality, and demographics will inevitably lead to health inequalities. Inequities, in contrast, refer to differences in health that are not only avoidable but also unfair and unjust (Braveman and Gruskin, 2003). Power, authority, and privilege drive health inequity. As we move towards interspecies and intergenerational health promotion, and work in the interplay between inequalities and inequities, the types and influences of power, privilege, and authority become more numerous and increasingly complex.

Equity is a useful concept to invoke when thinking through the determinants of health for all species and generations. Intergenerational equity is a guiding principle of sustainable development. The United Nations (UN) Brundtland Commission (1983) defined sustainable development as “development that meets the needs of the present without compromising the ability of future generations to meet their own needs” (United Nations World Commission on Environment and

Development, 1987). Interspecies equity, the consideration of non-human animals and their inherent self-interests alongside humans, together with intergenerational equity informs approaches to equitable sustainable development (Earnshaw, 1999). The United Nations Educational, Scientific and Cultural Organization (UNESCO) described interspecies equity as when people treat all creatures decently and protect them from cruelty and avoidable suffering (UNESCO, 2004): a concept not far removed from animal welfare (see Chapter 2 for more discussion on animal welfare). A new generation of work around the 2015 UN Sustainable Development Goals is seeking to redress the lack of consideration of the important roles of animal health to sustainability through integrated human, animal, and environmental frameworks. Nuanced thinking on interspecies equity necessitates careful consideration of their shared environments and of the myriad ways that health is generated, protected, connected, and distributed across social and ecological spaces, places, and times. This chapter explores how the concept of health equity might be adapted to One Health and allied fields in order to foster reciprocal care at the junction of animals, health, and society.


Equity is fairness in treatment, access, opportunity, and advancement for all. It is promoted by identifying and eliminating barriers to allow the full realization of opportunities by all groups. Health inequities arise when social, environmental, or ecological injustices prevent an individual, group, or population from meeting their potential. Health equity is tightly allied with notions of the universal right to health enshrined in international law. Factors that make it difficult to translate this moral notion into action include the reality that ideas about equity and health are context-dependent, informed by social and cultural values and traditions, and often constrained by political practices and economic priorities (Braveman, 2010). “In operational terms, and for the purposes of measurement, equity in health can be defined as the absence of disparities in health (and in its key determinants) that are systematically associated with social advantage/ disadvantage” (Braveman and Gruskin, 2003). The idea of health equity is mostly used in reference to disparities in health between different people due to differences in their access to the social determinants of health. Improving equity, therefore, most often involves increasing justice and fairness within the procedures and processes of institutions or systems, as well as in the fair distribution of resources. Health equity-informed work has an explicit focus on how inequities are often institutionalized and socially sanctioned (Krieger, 2014). Tackling equity issues requires an understanding of the root causes of disparities within our social world (Jones et al., 2009; Kapila, Hines, and Searby, 2016).

Differences in health status across human populations emerge because of ongoing marginalization and exploitation through discrimination based on categorized differences such as socio-economic status, gender, citizenship, geographic location, racialization, and sexuality. Discrimination is cumulative across the life course and is observable in the health gradient (Braveman and

Gruskin, 2003). Patterns of power and privilege are relational and many of the factors that disadvantage some groups simultaneously advantage others, for example, in the case of white privilege, poverty, and colonization. To successfully tackle human health inequalities requires working upstream to address the “causes of the causes of disparities and the causes that underlie the causes of the causes” (Greenwood and de Leeuw, 2012). Insights from research and practice around social inequities in human population health offer a way to think about determinants working across human-animal health continuums as well as to identify social, political, and economic factors that are impacting animal health. Protecting and promoting health determinants can advance equity work when patterns of discrimination, which may have played out across generations, are identified and redressed so that their impacts on current and future generations are stopped (Marmot et al., 2008). Table 3.1 summarizes some current health determinants thinking - with the recognition that this is an active and continuously evolving area of scholarship.

Our understanding of health determinants, as well as health equity, is constantly deepening. One way to progress our learning is to explicitly consider the philosophical and theoretical assumptions that inform current thinking, evidence building, policy formation, and practice. For example, scholars and practitioners are considering ways in which health determinants thinking both benefits from and is limited by its origins in Western philosophical and medical traditions. The Western worldview is anthropocentric and frames nature as separate from


Examples of Different Conceptualizations of Determinants of Health



Social Determinants of Health (SDoH)

Describes a range of personal, social, economic, and environmental factors that contribute to one's state of health, such as educational attainment, employment, gender, and income (Marmot, 2005)

Indigenous Determinants of Health (IDoH)

Indicates that for Indigenous peoples in addition to being impacted by the full range of SDoH. these populations are also impacted by a history' of colonization and that health and well-being require attachment and access to land and place and the right to cultural continuity (Greenwood and de Leeuw. 2012; King et al.. 2009)

Environmental Determinants of Health (EDoH)

Draws attention to how the physical environment, such as the built and natural environment (e.g. water or air quality), impacts health.

Ecological Determinants of Health (EcoDoH)

Involves the inextricable interdependence that human survival has on the existence of a healthy Earth system, including the valuing of resilient ecosystems and the health of other species (Parkes et ah, 2020)

culture, and it prioritizes humans over animals and economic growth over ecological resilience. The medical cosmology embodied in allopathic medical traditions tends to focus on illness and disease rather than on health and wellness; medical expertise is based on atomized rather than holistic approaches to the body, and the links between human and ecological health are often left unexplored. Other knowledge systems do not begin from these foundational assumptions as they are produced through different worldviews and offer frameworks for valuing the lives of humans, animals, and Earth, which are highly integrated. Indigenous approaches to health, for example, have for millennia viewed human health as inextricably bound to the health of family and community, the natural and the non-human world, and to land and water (FNHA, 2020). Human health is not of a priori importance; instead, a key guiding value is that human health is related to the health and well-being of the whole (Blackstock, 2007). Understanding the links between worldviews, social values and medical practices are important areas to reflect upon, particularly in the current context, where significant whole system problems are increasingly impacting health. For example, global pandemics, many of them zoonotic, are illustrating the inextricable links between human and animal health; climate change illuminates human dependence on Earth, while environmental degradation reminds us that health is dependent upon ecosystem services, such as the filtration of clean air and water. Issues of power, privilege, racism and other forms of discrimination add additional layers that need to be considered to understand what forces are driving and perpetuating social and environmental harms to health and well-being as well as where interventions are best targeted.

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