The Language Tricks That Let Health Inequity Off the Hook

A sharply satirical opinion piece published in PLOS Global Public Health has set out to expose the quiet vocabulary of evasion that dominates writing about health equity. Authored by Aaron Koay of the Institute for Global Health at University College London and Monash University Malaysia, together with Lisa Bowleg of the Intersectionality Training Institute, Po-Han Lee of National Taiwan University and Rochelle A. Burgess of University College London, the article takes its inspiration from Binyavanga Wainaina’s famous essay ‘How to Write About Africa’. Where Wainaina skewered the clichés of African storytelling, Koay and colleagues dissect the clichés of global health prose, showing how an entire field can describe injustice in words carefully chosen never to blame anyone for it. The result is a guide that reads as a manual for how not to write, and its targets are phrases that appear daily in policy reports, journal articles and funding applications.

The authors begin with the World Health Organization’s definition of health equity as the absence of unfair, avoidable or remediable differences among groups of people. That definition, they suggest, already contains the seeds of accountability: if differences are unfair and avoidable, then someone had the power to avoid them. Yet the standard rhetoric of the field works hard to erase that implication. Writers are urged to declare that no one must be left behind without specifying who is doing the leaving, who benefits from the leaving, or who has the power to stop it. Health inequity is thereby framed as a tragedy without authors, a wound without weapons, a crisis without beneficiaries. The grammatical sleight of hand is subtle but consequential: once suffering has no agent, it also has no obligation attached.

Central to the critique is the phrase ‘vulnerable populations’. The authors argue that this expression compresses long histories of oppression and discrimination into two convenient words. The honest alternative, they suggest, would be something far more uncomfortable: people whose lives are shortened by deliberate policy choices that protect the power and privilege of other groups. Vulnerability, in other words, is not a natural condition like weather. It is manufactured through underfunded welfare systems, the criminalisation of poverty, segregated urban planning, suppressed wages, restricted reproductive autonomy and denied access to healthcare for refugees. When analysts describe these outcomes as mere ‘differences’ or, in a more technical register, ‘disparities’, they strip them of causation. Differences simply exist; they do not bomb hospitals, gentrify neighbourhoods or decide whose suffering is unworthy of attention. Nobody’s fault, nobody’s bill.

The piece is equally scathing about the reflexive call for more research. The authors note that much of the evidence for health inequities has existed for decades, if not longer, yet the research gap remains the field’s favourite refuge. The moving goalposts are described with clinical precision: when evidence exists, call it low-quality; when it is high-quality, say it lacks specificity; when it is specific, say it lacks generalisability. If the evidence is quantitative, demand a double-blind randomised controlled trial; if it is qualitative, dismiss it as anecdotal. Research is genuinely useful, the authors concede, but in this rhetorical role it serves mainly to delay action, displace the testimony of affected communities and convert political failure into methodological uncertainty. A research gap, unlike a policy failure, can always be filled, and filling it requires no one to change anything.

Another familiar term under examination is the ‘social determinants of health’. Income, housing, education and employment are dutifully listed in countless papers, but the systems of power from which these determinants grow, including racism, colonialism, imperialism, capitalism, ableism and patriarchy, are rarely named. The authors insist that determinants must remain determinants, not decisions. The analytical move is to describe the symptoms of injustice without naming its architects. Asking who benefits from unaffordable healthcare, racialised policing, weak labour protections, segregated urban planning or the erosion of public services would transform a descriptive exercise into an accusatory one, and the conventions of neutral scholarship are designed to prevent precisely that transformation.

The satire then turns to the politics of pity that governs which populations get attention. Writers are advised to speak of reaching the ‘underserved’, but to choose the underserved carefully. Mothers and children are usually palatable, but only when they can be folded into a moral theatre of innocence and deservingness. Refugees and asylum seekers, people who use drugs, sex workers, queer and gender diverse people, racialised minorities and those who do not perform vulnerability correctly are more difficult, because their situations invite controversy rather than simple sympathy. The critique lands on a uncomfortable truth about advocacy: suffering that attracts sympathy is prioritised over suffering that demands structural change, and the groups made most disposable are left for later, if they are addressed at all.

Two fashionable words receive particularly pointed treatment. The first is ‘intersectionality’, a framework developed to describe how systems of power interlock and how people facing overlapping forms of marginalisation are pushed deepest into policy cracks. In much writing, the authors observe, it is reduced to a diversity of identities, a grocery list of gender, race and income level treated as if the roll call itself were analysis. The second is ‘resilience’. Poor families crowdfunding money for medicines, displaced people rebuilding lives after wars they did not choose and Indigenous communities defending their lands from environmental destruction are duly admired for surviving adversity. What goes unasked is why they must be resilient in the first place, and why the institutions that failed them are not required to change. Celebrating resilience, the authors imply, quietly relocates responsibility from states and systems to the people those systems have failed.

The procedural rituals of global health come in for their share of mockery as well. Intersectoral and interdisciplinary collaboration is praised as a panacea in which ministries, health professionals, researchers, civil society, philanthropic foundations and commercial actors whose business models actively harm public health all sit down together, with no discussion of conflicts of interest and no question about who holds power in the room. Lived experience is invited to the table, its bearers thanked for their courage, but never allowed to decide what should change; it should move the room, not move resources or authority. Recommendations are kept ambitious but toothless: empower communities, strengthen capacity, enhance coordination, while unfashionable solutions such as debt eradication, resource redistribution, public provision, legal reform and regulation are avoided. The best recommendations, the authors write acidly, are those that make everyone feel something is being done without requiring anything to change.

The article closes with two final rituals. The first is the call for ‘political will’, described as mysterious, like rain, expected to arrive once enough evidence is gathered, enough reports published and enough roundtables convened, while electoral incentives, commercial lobbying, institutional inertia and the possibility that some policymakers are perfectly willing, just not towards equity, go undiscussed. The second, and gravest, omission is accountability, which asks the wrong kinds of questions for neutral scholarship: who is responsible, what obligations were violated, and what justice would demand. The authors end with an image that is likely to travel far beyond public health: the impartial researcher who describes the fire, records its distribution and remains politically neutral about who keeps striking the match and who keeps withholding the water. Read as a whole, the piece is less a style guide than an argument that language is where accountability goes to die, and that the words a field chooses determine whose fires are studied, which are ignored and which are allowed to keep burning.

Subject of Research: Rhetorical conventions in health equity scholarship and how they obscure accountability for health inequities

Article Title: How (not) to write about health equity

Article References: Koay, A., Bowleg, L., Lee, P.-H., & Burgess, R. A. (2026). How (not) to write about health equity. PLOS Global Public Health, 6(9), e0007292. https://doi.org/10.1371/journal.pgph.0007292

Image Credits: AI Generated

DOI: 10.1371/journal.pgph.0007292

Keywords: health equity, global health, social determinants of health, vulnerable populations, intersectionality, health policy, accountability, PLOS Global Public Health, political will, public health rhetoric, structural inequality, research gaps