Is being a couch potato inequitable? Or hard questions about inequities

(Photo credit: Ian Burt)

In last week's article on equity, justice and global health, I took as a starting point Dahlgren and Whitehead's definition of inequity: an inequality is inequitable if it is avoidable, unnecessary, and unfair. Commenter Catee Lalonde critiques this view on three fundamental issues:

1. All (or almost all) inequalities are due to specific actions or inactions, and this by itself makes them unfair. Consequently, the definition is internally redundant.
2. Hardly any health inequality would be necessary if sufficient resources would be allocated to alleviate it. Consequently, the ‘necessary' part of the definition is externally irrelevant.
3. One could query the intrinsic meaning of ‘unfairness': Do choices that we make as a society and that lead to serious inequalities (Catee cites the way the US has organised its health care system) mean that they are self-inflicted and consequently not unfair?

These are hard questions, and very cogent ones. They are important, not only for the results they have on inequities and how we deal with them, but also because of the implicit questions they ask about global health in general: Is there a limit to health? Where does personal responsibility take over from society's? Could present-day health efforts impact negatively on tomorrow's health status? Can there be health inequities between societies, or only between individuals? And many others. I will go into Catee's first critique this week, and will write more about the other two next week.

However, I would first like to make a point about definitions in general and about this definition in particular. Definitions are not goals by themselves: we define things to help us in our discussions. They serve as shorthand, so that when we talk about ‘lions' we do not have to refer to ‘tawny coloured, social African and Asian predators, second-biggest in the genus Panthera, the male of which is easily recognised by its mane'; our meetings are long enough as it is. A definition's value is determined by how well it fits with our mental image of the concept it describes. Dahlgren and Whitehead's definition is definitely not perfect, but it is the best I have been able to find - others are just even further off. So if somebody here would come up with a better definition, either from literature or original, I would be more than happy to adopt it and use that in further discussions.

So let's start with Catee's first point. Personally, I do not see why any inequality due to specific action or inaction would by itself be unfair. We all make choices and need to live with the consequences, and that we make different choices with different consequences does not automatically make the results unfair. The stunt man, the hoon driver, the couch potato: they all make choices and the results, a drastically lower life expectancy for all three of them, are not automatically unfair. Of course, I purposefully muddied the water here by including that last example: society and how it is organised can have a big influence on e.g. physical activity, and hence couch-potatoness and its results can be unfair - but not automatically. I have friends who are well-educated, well to do, live in places that are just made for walking and bicycling - and still are couch potatoes, because they choose to be so. Unfair that they will live shorter lives? Hardly.