A Christian Critique of Equity

Posted on January 1, 2005

Most of us are involved in CCHFbecause we not only care about sick people; we also care about poor people. We long for “justice for the poor”, and sometimes advocate for that end. We identify health inequities and try to correct them. But what ought we specifically to be seeking? What is our biblical calling when it comes to poverty? If the poor will always be with us, where does that leave us?

 

Biblical Roots

Equity is a biblical word. It’s the English transla tion of one of several Hebrew words (miyshor and related words) for “justice” (used more in the King James Version than in more modern translations). The word translated “equity” comes from a root which means “straight” or “level.” It’s the same word used in the Isaiah 40 passage “make straight in the wilderness a highway for our God” and “the rough ground shall become level.” Today, we might use equity in the sense of a “level playing field.”

In the Psalms, God judges people with equity (Psalm 96:10, 98:9, 99:4. All biblical references are from the Jerusalem Bible, unless otherwise noted). In Proverbs, a reason for seeking wisdom is to learn to practice equity, sometimes translated “fairness.” Malachi (2:6) reminds us that the early priests walked in equity, or uprightness; Micah (3:9) condemns the leaders of Israel for perverting all that is right, or all equity. In both of these prophetic passages, the opposite of equity comes from a word meaning “crooked,” which the King James Version translates iniquity. Today we are more likely to call this “wickedness,” but the English words iniquity and inequity come from the same root, and both still mean “lack of justice.”

Equity, then, originally meant justice, both in the sense of fairness (the level playing field) and in the sense of uprightness (a ”straight” standard). This is the way God deals with people: fairly, and according to a standard. It is also the way we should deal with each other. When we don’t, inequity (or iniquity, or wickedness) results.

 

Equity Today

As with many words, the meaning of equity is evolving. It has reached its most reduced and technical meaning in finance, where it means simply the monetary value of something: if I bought a piece of land for $10,000 and still owe $7,000, I have $3,000 equity in the land. If I haven’t finished paying off the loan, I suppose it is only fair to admit that what I have paid off is mine, and what I have not paid off is not.

As a legal term, equity used to refer to a system of courts that could ignore technical legal rules when those rules seemed to prohibit What was fair.

Today, in domestic and international relations, equity has retained this sense of fairness. The Equity Gauge, a South African organization, says, “Equity means ‘fair shares’ and ‘fair opportunitiesthe difference” - but not necessarily equal shares and equal opportunities. An excellent cartoon on its web page clearly illustrates

Equality is a government tax man taking 5 Rand both from the poor man with the bicycle and the rich woman next to the big car. Equity shows the tax man taking 0.5 Rand From the poor man and 50 Rand from the rich woman. In the cartoon, the poor man looks much happier with equity; the rich woman looks happier with equality. (1)

Like equality, however, “equity is a measure that compares one group with another.” (2) Equity in international health or public health within the U.S, for example, looks at “differences in...aspects of health across...population groups.” (3) Thus equity, while retaining the old meaning of fairness, has become a specific technical term for quantifying those differences, and for measuring the unfairness. Since both equity and equality involve measuring, it is perhaps not surprising that there is still some confusion between the two terms. The International Society for Equity in Health (ISEQH), from which the last quote was taken, sometimes refers to “inequalities” and sometimes to “inequities,” appearing to refer to the same thing; the Health Equity Network uses the phrase “equity and [its implied opposite] inequality” throughout its website. (4)

Is it important to keep these two concepts separate? On the one hand, it may not be. If equity is primarily a tool to measure differences between two groups, and it is self-evident that the differences are unfair or unjust - one group having a higher mortality rate than the other, for example - then it matters little whether we call this inequality or inequity. In Dying For Growth: Global Inequality and the Health of the Poor (5), it is clear that global inequality is also inequity - that is, unfair.

On the other hand, it may not always be self evident that the differences are unfair. For example, If the average life expectancy of a certain group is 39, we agree there is an inequity compared with a group having an average life expectancy of 70. But if another group has an average life expectancy of 87, is that group necessarily better off than the other two groups? Are the older people healthy and happy, or bed-ridden and senile and on a dozen medications? Or this: is a low patient:doctor ratio (say, 600:1) always better than a high one (3000:1)? Perhaps the place with the high ratio is making better use of mid-level practitioners; perhaps the place with the low ratio has most of its doctors doing research.

The idea of equity can lose something when it becomes only a tool for measuring differences. The real question is Whether or not these differences are fair and whether or not they imply an injustice. Equity in its full sense can never be merely a comparison; to imply justice, it must evaluate the differences. The Hebrew word for equity, remember, meant not only “level” but also “straight,” or according to a standard. However, the standard implied in current discussions of equity is merely the group with the better statistics. How do we decide what is fair?

Before engaging this question further, I want to consider another aspect of equity in domestic and international relations: its link to advocacy. People who talk about inequity obviously want to reduce it. Equity policy and actions are therefore “policy decisions and programmatic actions directed at improving equity in health or in reducing or eliminating inequalities in health.” (6) These decisions and actions may be carried out by those who run local public-health programs. More often, however, the decisions and actions needed are on a national or international level, a place at which there are other forces advocating policies that may have negative impacts on health— impacts that will increase inequities. A recent WHO meeting on Health and Poverty marked a growing consensus that “the health community...needs to be engaged in a dynamic political process...to put health as central to fair and equitable development.” In order to do this we need, in the words of one participant, to “step out of the biomedical paradigm and become unashamed social activists.” (7)

The sentiment is not new. In the mid-nineteenth century German medical researcher Rudolf Virchow concluded that “the physician had to concern himself with the total environment of human beings and therefore could not avoid taking part in political action.” (8) A hundred years later, physician Che Guevera was instrumental in the Cuban revolution for the same reasons. The need to go beyond the biomedical paradigm is no less relevant today, despite its dramatic successes.

However, it is less clear today what form that social activism should take. The most extreme form, revolution, is falling out of favor, partly because so many revolutions have turned sour. Yet the advocacy activities I have seen proposed - tinkering with economies, government initiatives, foreign aid - all seem to be palliative measures for a dying world. They remind me of the tinkering we physicians do for patients with diseases like diabetes or heart failure or AIDS: unable to offer cures, we tinker with a person’s physiology. The irony of current advocacy is that, far from stepping out of the biomedical paradigm of tinkering, it is deeply rooted in that same paradigm. But what else can we do?

 

Another Biblical View

The two unanswered questions in the previous section (“How do we decide what is fair?” and “What else can we do besides advocacy?”) suggest to me the need to look more closely at current conceptions of equity and advocacy. One way to do this is to return to the Bible, this time to the New Testament. I couldn’t find the English word equitythere. Yet the parable of the workers in the vineyard, and the context in which Jesus told this parable (Matthew 19:16—20:16) provides a startling critique to the assumptions underlying today’s conversation about equity and advocacy.

The parable itself is one of the more enigmatic ones. A landowner hires some people for a day’s work in his vineyard and offers to pay them the normal daily wage. A few hours later, he hires some more people, offering to pay them an “equitable” or “just” (dikaios) wage. Again at noon, at 3 P.M., and even at 5 P.M., he hires more workers. Then at the end of the day he pays them all exactly the same amount. The workers hired first are naturally unhappy and complain that he has made the recently hired workers “equal” (isos) to themselves who worked all day — and that that wasn’t fair. The landowner replies that he is not being unjust (adikeo, the opposite of dikaios) if he chooses to be generous to those he hires last.

On one level, the parable is a nice illustration of the difference between equality and equity. The workers hired first believe in equality - equal pay for equal work. The landowner believes in equity, or justice, claiming that he was not unjust in paying the first-hired workers the normal just wage; he was simply being generous, or intrinsically good (agathos), in paying the last-hired workers the same amount. However, this is not the equity that we expected. There are few clues as to why the landowner was being fair. Possibly those hired last were victims of a high unemployment rate in the country, but the landowner - and Jesus - make no such clear political or economic statement. The workers hired first, and the listeners, are left to puzzle over the story, and the even more puzzling conclusion that. “the last will be first, and the first will be last” (Matthew 20:16). How can that be fair?

The context in which Jesus told this story helps us to enter more deeply into that question. The conversation begins when a rich young ruler approaches Jesus and asks him what good thing (agathos) he must do to gain eternal life. Jesus tells him to obey the commandments. He is persistent: which ones? Jesus lists a few. The rich man is even more persistent: he has kept them all, he says. What else is needed? Jesus knows that this persistence is bringing the conversation to the heart of the matter and that what he is about to say will either liberate or destroy the rich man. So Jesus looked at him and loved him (see Mark 10:21) and told him to sell all he had, give it to the poor, and follow him.

When the rich man could not see the liberation in this and went away sad, Jesus remarked how difficult it was for rich people to enter the kingdom of God harder even than a camel to go through the eye of a needle. The radicalness of this statement impressed even the disciples, who were by no means rich and had already chosen to follow Jesus. Who then, they asked (possibly remembering their own few remaining possessions), could be saved? Jesus confirmed their suspicion that it was humanly impossible, but he then brought the discussion back to the spiritual plane where it belonged. With God, all things were possible.

Peter, however, possibly seeking a front-row seat in the kingdom, pushed further. “We’ve done pretty well, haven’t we?” he asked jesus. Well, yes, said Jesus, but be careful about trying to get those front-row seats. Then Jesus told the parable of the workers in the vineyard. Yes, Peter, he seemed to be saying, like the workers hired first, you will be rewarded justly. But there are no front-row seats in the kingdom.

What does this passage tell us about equity and advocacy? It begins with a question about what is the good thing (agathos) necessary for participation in the kingdom of heaven, and ends with a confession that the landowner did a good thing (agathos) in paying the last-hired workers so well. The topic is intrinsic goodness, but the background is clearly poverty and equity. There can be no true goodness without addressing poverty. However, the “solutions” for reducing poverty are not what we expect, and at first are not very satisfying.

There is, first of all, no plan and no promise to eliminate poverty. Injustice, oppression, and the resulting poverty are clearly condemned throughout the Old Testament, and we are constantly encouraged to stand against them. But Jesus was no more optimistic than “the poor you will always have with you” (Mark 14:7, NIV), and gave no prescription for eliminating poverty. His concern instead seemed to be the elimination of concentrations of wealth.

What he told the rich man in Matthew was the same instruction he gave to all of his disciples in Luke 12:33 (NIV): “Sell your possessions and give to the poor.” That does not eliminate poverty, but it does make clear that there is a connection between concentrations of wealth and poverty, and that poverty reduction costs something. Jesus’ focus seemed to be more on the problem of wealth than on the problem of poverty.

In the parable of the workers in the vineyard, Jesus at first seems to be showing us the difference between equity and equality, coming down clearly on the side of equity. But a deeper look is again less than satisfying: He gives no clear reason why the workers hired later should be treated so well.

He is against “equality,” but gives no clear picture of how we can employ “equity” - any more than he gives a clear outline on how to reduce poverty. We are merely challenged to address poverty by reducing our own wealth, and to somehow go beyond equality. But these “mere” challenges, unsatisfying as they at first seem, can lead us toward a Christian approach to equity and advocacy.

 

The Christian in the World

To summarize the argument so far: Injustice and oppression cause poverty. Equity, in its full sense of fairness and justice, is encouraged; its opposite, iniquity, is condemned. However, there are no clear political guidelines for Christians in the New Testament. Current research in domestic and international health care and international relations has exposed marked inequalities and inequities in health and social statistics. These differences strike us as wrong, and we want to do something about these differences.

Jacques Ellul helped us to think through issues like these with a question he posed in 1948:

What part should the Christian play in these questions? First of all, it is not for him to define the problems in the same terms as those who have no faith; it is not for him to tinker with futile attempts at technical and moral ‘solutions’; his job is to discover the real spiritual difficulties Which every political or economic situation contains. So far as the solution is concerned, it cannot be a rational one: it can only be a solution in terms of life. (9)

Jacques Ellul wrote those words while reflecting on his involvement in the French Resistance during World War II, as well as on the problems of reconstruction in Europe. His meditations apply equally to involvement in equity issues and advocacy, and the following comments rely heavily on the first chapter (entitled “The Christian in the World”) of his 1948 book.

The challenge implicit in the Ellul quote is that Christians need to think biblically about the same problems that everyone else is concerned about. We need to grapple with the same questions that journalists and politicians and researchers present, but not necessarily in the same way. Our faith, our worldview, and our goals all give us a perspective that may help the world to see the problems differently. The goals of some political and economic programs may be consistent with our biblical view, but that does not mean that Christians are obliged to join those programs. Of course we may choose to join those programs, but joining will not automatically fulfill our biblical responsibility.

How does this apply to equity? As a tool, a “measure that compares one group with another,” equity can precisely point out where one population has “poorer” health statistics than another. However, since as Christians we are more concerned about injustice than mere inequality, we can analyze the differences and try to pinpoint the injustices. But we can also suggest where the differences may simply reflect different cultural norms, or may even point toward strengths in the “poorer” population. True equity — or fairness, or justice — means that we not simply treat poorer populations objectively as victims, but also subjectively as sources of wisdom that may feed us.

The last half of I Corinthians 1 illustrates this. Paul contrasts conventional wisdom with the “foolishness” of the cross, and contrasts conventional wise people with those Whom “the world thinks common and contemptible” (see I Corinthians 1:27-29) — the latter being the ones that God has chosen. This is equity: God making right what the world made wrong.

What about advocacy? Advocacy, usually in the corridors of power, is one response to the injustice uncovered by equity research. It is a logical response: if the basic problem is with the powerful, we should talk to them, clarify the effects of their policies on the poor, and request (or plead or demand?) that they change. We should, together, expose the injustice and propose alternatives and lobby for their adoption. This is the most basic route we can take, and for those Christians who can navigate the corridors of power, who are called to work there, advocacy is an obligation.

But political and economic advocacy is not the only Christian response to inequity, and despite its logic, advocacy is not the most distinctly Christian response. Sin, or iniquity, is woven into the worldsystem so tightly that correcting it would involve unraveling the entire world system. We cannot accept that system since it is unjust, but we also cannot Fundamentally change it. If, by advocacy, we are trying to create a new world, we are deceiving ourselves. If, on the other hand, we opt for personal evangelism only, we have ignored the biblical mandate to seek justice. We appear to be caught between a rock and a hard place.

We are - until we reread the Gospels. Jesus’ words are freeing. He says that we are salt and light, preservers and illuminators. Our lives in this iniquitous world are to preserve the created goodness that is still there, to illuminate where it still is and where inequity has overcome it. Preserving and illuminating does not change the world, but it clarifies where the change is needed and prepares the world for change. It relieves us from the pressure to be successful in changing the world.

But we do have a task, and it is sometimes costly. In order to preserve created goodness, we have to look for it and recognize it and articulate it, looking especially in places “the world thinks common and contemptible.” And to illuminate both that created good and the places where iniquity has overcome it, we need to live in those places. They may be corridors of power or corridors of a prison; they may be the inner chambers of Congress or the streets of an inner city; they may be refugee commissions or refugee camps. All of those places need salt and light — and our coworkers in advocacy and service will likely need the salt and light as much as the powerful and the poor. But the only way we can be salt and light, the only way God can use us in those places, is for us to go to those places and live in the tension of a world we can neither change nor accept as is.

I want to conclude this section by looking at another quote from Jacques Ellul and considering how it might apply to equity and advocacy:

Thus, when we were confronted by Hitler — if it be true that he represented a satanic power — first of all there was a spiritual conflict to be waged. It is prayer which should be decisive, but we no longer have any confidence in the extraordinary power of prayer. Prayer is the power which exorcises demons, by the Holy Spirit, and it is thus the weapon of faith. It is quite possible that if Christians had really acted in this way, While everyone else Was thinking only of the material war (which also had to be waged), or of simply blessing the guns, the solution would not have been this terrible triumph of the Nazi spirit that we see everywhere in the world to-day (10).

At first the parallels are easy to see. Ellul was speaking about Hitler; we have been considering inequity. Ellul recognized that the war needed to be fought; we have affirmed the need for advocacy. Ellul said there was another distinctive task for Christians, that of identifying and waging the spiritual conflict; we have suggested that political and economic advocacy is not enough, and that Christians concerned about equity need to divest themselves of their own wealth and go to be salt and light in places of poverty and tension.

But what did Ellul mean, writing in 1948, when he spoke of “this terrible triumph of the Nazi spirit that we see everywhere in the world to-day”? Hadn’t the Nazis been roundly defeated? Yes, the Nazi party had been defeated, but fascist Nazism - the forcible suppression of opposition, the belligerent nationalism and racism, the aggression, the glorification of war - none of this had been eliminated. When the material conflict proceeded without addressing the spiritual conflict, only the material enemy was defeated.

What is the parallel to equity and advocacy? Perhaps we can get a glimpse when we consider the effects on the poor of the Two-Thirds World from Structural Adjustment Programs, meant to improve the economies of poor countries. Very often the poor continue to get poorer, even while the economies grow. The war on poverty becomes a war on the poor. Or in our own country: we send more and more people to jail for minor offenses to keep the streets safe for the poor who live there. We end up overfilling our jails — with poor people. These strategies do not help in eliminating inequity, because we haven’t addressed the spiritual conflicts. The point for us is that we must be vigilant as Christians in doing what only Christians can do, and that is to identify the spiritual conflict and engage ourselves with it.

Conclusions

1. Equity, as the word is used in domestic and international relations, is a comparison, a measure, a tool. Equity in the Bible means justice: fairness and uprightness. There is clearly an overlap in these concepts, and the modern usage can point to inequity/iniquity. Our concern as Christians should focus not where the inequity is mere inequality, but where it is injustice.

2. While seeking equity may be desirable, it cannot be our final goal. When we look at the differences uncovered by equity comparisons, we need to evaluate them. The spiritual person, says Paul, “is able to judge the value of everything” (I Corinthians 2:15).

3. Advocacy on behalf of the poor and powerless is good, but it is not enough. The biblical mandate to address world poverty seems to be for us to divest ourselves of our wealth, use it for the poor, and then depend on and follow Jesus. Since not everyone will do this, poverty will not be eradicated.

4. Our task as Christians is not simply to advocate for the poor and powerless in the same way as everyone else is, but to address and articulate the underlying spiritual conflicts uncovered by equity measurements. This may involve political and economic advocacy, but that will not be our distinctive Christian contribution.

Raymond Downing, M.D., serves with the Indian Health Service in Fort Defiance, AZ. At the time of completing this article, he was serving in Lugulu, Kenya. His newest book is As They See It: The Development of the AIDS Discourse, Adonis and Abbey Publishers, Ltd, 2005. He describes it as his “attempt to address inequity in the global discourse on AIDS — not just in who gets AIDS or who gets treatment, but in who we listen to as we plan how to approach the epidemic.” He can be contacted at armsdown2001 [at] yahoo [dot] com.

ENDNOTES

1. The Equity Gauge, www.hst.org.za/hlink/equity.

2. Ibid.

3. International Society for Equity in Health,www.iseqh.org.

4. Health Equity Network, www.ukhen.org.

5. Jim Young Kim, Joyce Millen, Alec Irwin, and John Gershman (eds.), Dying for Growth: Global Inequality and the Health of the Poor, (Common Courage Press, 2000).

6. ISEQH.

7. Personal communication from Ray Martin, Feb. 2, 2002, in which he cited a bulletin on poverty and health produced by Healthlink Worldwide on behalf of the International Poverty and Health Network in association with WHO. It is intended to produce this four times per year. More information is available at www.iphn.org

8. Rene Dubos, The Mirage of Health (Harper and Row, 1959), p. 118.

9 Jacques Ellul, The Presence of the Kingdom (Seabury Press, 1967), p. 18.

10 Ibid., p. 25.

Tags: H&D, Cultural Issues, Healthcare System

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