Introduction

There is a critical difference between ‘equity’ and ‘equality’. Equality is about everyone receiving the same input through equal treatment.  Equitable treatment ensures that the different needs of people are met to ensure fair and just outcomes.

For example, equality would be giving every patient the same broad-spectrum antibiotics. Equity would be giving an antibiotic specifically targeted to the patient's needs.  Another example of equality is that all patients are allowed two visitors to the ICU. An equitable approach would be to provide a large waiting area for those with larger or extended families.  

Equity and equality are often mistakenly conflated as interchangeable terms relating to fair treatment and justice. In reality, there is a critical difference between the two terms. 

Equality is concerned with sameness and focuses on inputs. Equality is about everyone receiving the same equal treatment. The issue with equality is that people have different needs and come from different places. Treating everyone the same through equal input can result in unjust and unfair outcomes. On the other hand, equity is concerned with fairness, and is focused on outcomes.  Equitable treatment ensures that the different needs of people are met to ensure fair and just outcomes.

Equality assumes everyone starts from the same place. Equity acknowledges that people have different histories, experiences and opportunities. It is only through addressing these different needs that health outcomes of Indigenous Peoples will be improved.

Select each heading to learn more. 

Reflection on the ICU environment and decision-making in ICU by Dr Penny Stewart

Aboriginal and Torres Strait Islander peoples have a different connection to country. Aboriginal and Torres Strait Islander people often say they do not own the country – instead the country owns them. How different is this from our white vision of ownership? 

For Aboriginal Peoples the relationship to land leads to responsibility to ensure they respect the land so that they only take from the land what the land gives them, and they take in a way so as not to change the land. They adapt their needs to what the country can give them. Westerners change the land to suit their own needs. 

My husband Bob, an Arrente Aboriginal man once remarked he could not understand why European people always came to Alice Springs and wanted to buy a house with a pool. I, like other European people wanted to have a pool as it is hot and dry in Alice Springs and the pool adds to my comfort. Bob in contrast would not go to the desert if he wanted a pool. He reflects the Aboriginal view that you adapt to what the land offers you, while I was of the white view, of course you adapt the land for your own needs. 

This is a fundamentally different way of viewing the world. Westerners have dominated the way the land is used. Think about the ICU – the space prioritises how we treat and how we control risk. The beds are often in single rooms rather than allowing people to be with relatives, we clean but do not cleanse the unit after people have died in the unit, and so from an Aboriginal point of view often spirits remain in the ICU. The environment is climate controlled according to safe hospital regulations; flowers, plants and access to the outside are not allowed due to infection control. The spaces and the regulations are made for small families, often with little ability for even one person to stay alongside the patient is often difficult to negotiate. The numbers of family that would want to stay by the patient side is never possible.

A western view of autonomy drives the discussions of how the disease and the treatments will affect the individual patient. 

Aboriginal and Torres Strait Islander decision making also reflects who will be taking responsibility for the decision as well as the patient. For instance, the decision to have a leg amputated will involve the consideration of how the patient will live on the land and who will be able to help them navigate this. The right person who will take responsibility for this decision must be involved in the consent process. This will not always be the next of kin from a Western viewpoint. The need to have the right people for the consent process is an example why discussion with the Aboriginal liaison officers is so important prior to obtaining consent so the right people are in the discussion and you know the information that they need to make the correct decision for them.

	Activities to facilitate learning

The following activities will enhance your learning on this topic.

	Consider

Consider the outcomes for Aboriginal and Torres Strait Islander Peoples as discussed in Secombe et al. (2019) and the need for equitable and culturally safe care to address these outcomes (summary below). 

When looking at critical illness, there are clear differences between Indigenous and non-Indigenous Australians. While overall mortality (ICU and hospital) is similar, Indigenous populations have a lower median age at admission to ICU, are more likely to require emergency admission, and are more likely to require ICU readmission. Indigenous Australians are more likely to present to ICU with sepsis and trauma, and less likely to present after elective surgery. 

These findings may be explained by access barriers for Indigenous populations to receive culturally safe and clinically appropriate primary health and subspeciality care.

If you would like to read full article it is available here.

	Watch

1. Watch the video Deadly Heart

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	Consider

1. Consider the social determinants of health and how that intersects with poor outcomes when combined with high burdens of chronic disease, poor disease literacy and untrusted health systems.

	Additional recommended resources

You are encouraged to source other information about this topic independently. Additional recommended resources for optional further learning are:  

1. Review the World Health Organisation website on Health Equity
   

Reflect on your learning Select the image to answer the reflection question for this topic.