Maxwell J. Smith details our inconsistent commitment to equity during the COVID-19 pandemic and argues that those willing to declare commitments to equity must be held accountable for acting in accordance with that which equity demands.

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The word “equity” has received a lot of airtime during the COVID-19 pandemic. It has rolled off the tongues of politicians and health authorities all over the world. Perhaps too easily. It also adorns the values statements of hospitals and public health agencies. But it is often absent from their corridors. Interest in equity has become ubiquitous, but for too many this interest appears to be merely academic or intellectual, or perhaps even rhetorical; it is something we say is important, or at least something we want others to know we think is important. But when equity demands actual responsibilities or sacrifices – personally or collectively – it is too often ignored.

Getting people to care about equity can be difficult. But it shouldn’t be difficult to get the people who insist they care about equity to care about equity. And yet, this seems to be difficult, too. Consider the following four examples from the COVID-19 pandemic.

Photo Credit: Wikimedia Commons. Image Description: A Surgical Face Mask.

First, when it came to the rollout of COVID-19 vaccines, equity-minded folks rightly decried the state of global vaccine inequity. Yet, when some suggested Canada should heed the calls of the WHO to defer booster shots until those in low- and middle-income countries had the opportunity to receive their first doses, they were accused of having no regard for the well-being of vulnerable Canadians. And while national guidance for distributing booster doses laudably acknowledged global vaccine inequity, such guidance stopped short of recommending steps to effect a better balance of public health benefits between its own population and populations elsewhere (as it was often not their remit to do so). So, we must ask: if a resource is truly scarce, what does a call for its equitable distribution entail, really, if we are unwilling to accept any trade-offs to achieve it?

Second, much effort was devoted to designing vaccine allocation schemes that would be equitable by identifying at-risk population groups and prioritizing them accordingly. Yet, when critics pressured authorities to privilege “speed over precision” or “speed over fairness”, we were quick to compromise on equity. Often, this came in the form of proposals to “just use age” to guide vaccine allocation. (As a member of Ontario’s COVID-19 Vaccine Distribution Task Force, I was often met with this proposal.) I argued in The Lancet that, in addition to simply being easier, much of this pressure and its attendant impacts on equity were likely due to our obsession with vaccine trackers. After all, vaccine trackers tend to measure just one thing: speed – doses administered to date, doses administered per day, doses administered per 100 people. And when another jurisdiction fared better in this regard, your jurisdiction was accused of being “too slow” and told to “speed up”. Evidently, this was a more forceful criticism than being accused of being “inequitable”, despite declared commitments to equity. And while speed of vaccine rollout is important, proceeding in whichever way is quickest is likely to undermine equity objectives, as vaccinating the hardest to reach or most at risk won’t always be the fastest. So, we must ask: what does it mean to distribute a resource equitably if we are unwilling to tolerate anything but the fastest possible strategy for distributing that resource?

Third, if public health authorities recommend wearing a high-quality mask or respirator, then it is not only imprudent to forgo a mask, it is inequitable. This is because the measures recommended by public health authorities are especially important for the protection of those most at risk. Yet, in the face of such recommendations, many so-called proponents of equity are unwilling to put their mask where their mouth is. Curiously, they point to their low personal risk, their preference to not mask, or dubious worries about their “immunity debt”, not the risk they may pose to others. Not only is equity not their first concern, it doesn’t appear to figure at all. So, we must ask: what do commitments to equity entail, really, if equity-promoting actions are so easily defeated by a personal preference to not do them?

Fourth, consider recent moves by hospitals and other health institutions to remove masking requirements (sometimes only to be quickly reinstated). Decision-makers sought to justify such policy changes via risk-benefit analysis, due to the putative burdens on health care providers who must mask for long periods of time, and even because we’ve all missed seeing smiles. It’s certainly possible to justify the removal of masking requirements in hospitals, but it’s more difficult to do so if there’s an expectation that decision-makers reason from their institutions’ declared values. Values-informed decision-making requires that we reason from declared values to inform decisions. It is difficult to see how reasoning from “patient-centredness”, “inclusion”, or “equity” would lead to the removal of masking requirements unless doing so would specifically be in the best interests of the most at risk and least advantaged. So, we must ask: what do commitments to equity entail, really, if we do not place the needs and interests of the least advantaged and most at risk at the fore when designing policy?

Interest in equity has become ubiquitous in health care, public health, and bioethics. Yet, if we are unwilling to take any responsibility, make any sacrifices, or accept any trade-offs in service of advancing equity, then we are not truly committed to equity. If we are committed to anything at all, it seems we are committed to “equity lite”, where equity is pursued only so long as it is convenient to do so. Fortunately, given the ubiquity of declared commitments to equity in health care, public health, and bioethics, a straightforward remedy exists: accountability. It is time that those willing to declare commitments to equity be held accountable for acting in accordance with that which equity demands.

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Maxwell J. Smith is the Western Research Chair in Public Health Ethics in the School of Health Studies, Faculty of Health Sciences, and Associate Director of the Rotman Institute of Philosophy at Western University. @maxwellsmith