Comparative Analysis of Theorizing Health Equity in Amartya Sen’s “Why Health Equity?” and Christopher Williams et al.’s “Public Health Liberation”

By Grok, prompt ("Ignore previous chats. Read both manuscripts thoroughly. Compare these manuscripts on quality of theorizing health equity. Indicate preferred. Write extensive academic essay.") In a seprate chat, Grok had chosen Sen's article as the very best manuscript on theorizing health equity.

This essay undertakes a detailed comparison of two manuscripts concerning their theorizing of health equity: Amartya Sen’s “Why Health Equity?” (2002), a guest editorial published in Health Economics, and “Public Health Liberation - An Emerging Transdiscipline to Elucidate and Transform the Public Health Economy” by Christopher Williams and colleagues (2022), published in Advances in Clinical Medical Research and Healthcare Delivery. Health equity, broadly understood as the fair and just opportunity for all individuals to achieve optimal health, is a critical concept in public health and social justice discourse. The analysis evaluates the quality of theorizing in both works based on four key criteria: conceptual clarity, theoretical depth, scope and multidimensionality, and applicability and practicality. After a thorough examination, this essay argues that Sen’s manuscript provides a more robust and compelling theoretical framework for health equity, though Williams et al.’s work offers valuable insights into practical applications and community-driven approaches.

1. Overview of the Manuscripts

1.1 Amartya Sen’s “Why Health Equity?”

Amartya Sen, a distinguished economist and philosopher, delivers a keynote address that situates health equity within his broader framework of social justice and human capabilities. Published as a guest editorial in 2002, the manuscript argues that health equity is not merely about equalizing health outcomes or healthcare distribution but is a multidimensional concern integral to human freedoms and capabilities. Sen critiques narrow approaches to equity, emphasizing the need to consider social arrangements, economic allocations, and procedural fairness alongside health achievements.

• Key Arguments:

  • Health equity is central to social justice because health is a critical constituent of human capabilities.

  • It transcends the distribution of healthcare, requiring attention to broader determinants such as income, social inequality, and epidemiological factors.

  • Procedural fairness is vital, as illustrated by his rejection of discriminatory healthcare allocation to equalize health outcomes (e.g., reducing women’s care to match men’s life expectancy).

  • Sen critiques specific proposals like the “fair innings” approach, advocating for a broad, inclusive framework over unifocal metrics.

Sen’s theorizing is philosophical and foundational, aiming to define the conceptual underpinnings of health equity within a justice framework.

1.2 Williams et al.’s “Public Health Liberation”

“Public Health Liberation” (PHL), authored by Christopher Williams and a diverse team including community advocates, proposes a transdisciplinary approach to accelerate health equity. Published in 2022, this manuscript integrates philosophy, theory, practice, research, and training to address systemic health inequities. Drawing from the authors’ experiences in marginalized communities (e.g., Flint, Michigan, and Washington, DC), PHL introduces the “public health economy” as a lens to analyze economic, political, and social drivers of health inequity, emphasizing liberation and community empowerment as transformative mechanisms.

• Key Arguments:

  • The public health economy encapsulates the anarchic interplay of agents and forces perpetuating health inequity.

  • Liberation, both a mindset and practice, is essential to overcoming structural barriers, supported by concepts like “liberation safe spaces” and “illiberation.”

  • Horizontal and vertical integration broaden public health discourse and intervention scope, involving affected populations and the entire public health economy.

  • Theories such as the Theory of Health Inequity Reproduction (THIR), public health realism, and hegemony provide explanatory models for systemic change.

Williams et al.’s work is ambitious and interdisciplinary, blending theoretical innovation with actionable strategies rooted in community advocacy.

2. Comparative Analysis

The quality of theorizing health equity in these manuscripts is assessed across four dimensions: conceptual clarity, theoretical depth, scope and multidimensionality, and applicability and practicality.

2.1 Conceptual Clarity

Definition: How clearly and coherently do the authors define health equity and its components?

• Sen:
  Sen offers a precise and philosophically grounded definition of health equity, embedding it within his capability approach. He distinguishes between health achievements (outcomes), capabilities (opportunities to achieve health), and healthcare distribution, arguing that equity involves all three but cannot be reduced to any single aspect. His critique of overly simplistic metrics (e.g., health inequality as the sole measure) sharpens his conceptualization, making it accessible yet nuanced. For instance, he uses the example of gender disparities in life expectancy to illustrate why health equity must prioritize fairness over mere equality of outcomes.

• Williams et al.:
  The authors build on existing definitions of health equity (e.g., “fair and just opportunity to be as healthy as possible”) but extend it through the lens of the public health economy and liberation. They define health equity as the elimination of disparities by reconciling systemic forces, yet their conceptualization is less precise. The introduction of multiple novel constructs—e.g., “Gaze of the Enslaved,” “Morality Principle,” “illiberation”—enriches the discussion but risks diluting focus. The boundaries of health equity remain fluid, as the emphasis shifts toward systemic transformation rather than a standalone definition.

Assessment: Sen excels in conceptual clarity, providing a well-defined, theoretically anchored framework. Williams et al.’s approach, while innovative, sacrifices precision for breadth, leaving health equity less distinctly outlined amidst a plethora of new ideas.

2.2 Theoretical Depth

Definition: How well do the authors ground their arguments in established theories or develop new theoretical insights?

• Sen:
  Sen’s theorizing is deeply rooted in his capability approach and prior works like Inequality Reexamined (1992). He engages with philosophical traditions (e.g., Rawlsian justice) and critiques utilitarian and distribution-independent approaches (e.g., DALYs), demonstrating intellectual rigor. His argument that health equity is a distinct yet embedded aspect of social justice is systematically developed, with counterarguments (e.g., subsumption under resource equity) addressed through logical reasoning. The critique of the “fair innings” proposal exemplifies his ability to refine theoretical constructs while maintaining coherence.

• Williams et al.:
  PHL draws eclectically from political theory (e.g., Madisonian factionalism), sociology (e.g., Parsons’ AGIL paradigm), and emancipatory traditions (e.g., Douglass’s writings), creating a novel synthesis. Theories like THIR, public health realism, and hegemony are original contributions, offering explanatory power for systemic inequities. However, the integration of these diverse strands is less cohesive, and some concepts (e.g., “illiberation” vs. internalized oppression) lack rigorous differentiation from existing literature. The theoretical framework feels exploratory rather than fully unified.

Assessment: Sen’s work exhibits greater theoretical depth due to its rootedness in a well-established framework and systematic argumentation. Williams et al. innovate boldly but present a less polished, more fragmented theoretical structure.

2.3 Scope and Multidimensionality

Definition: Do the authors account for the multidimensional nature of health equity, including social, economic, and political factors?

• Sen:
  Sen explicitly advocates for a multidimensional approach, arguing that health equity encompasses health achievements, capabilities, healthcare processes, and broader social determinants (e.g., income, gender, social inequality). He emphasizes the interplay between health and other domains of justice, using examples like resource allocation to illustrate systemic connections. His rejection of unifocal criteria (e.g., equal health distribution) underscores his commitment to complexity, though he focuses more on conceptual breadth than specific determinants.

• Williams et al.:
  PHL also embraces multidimensionality through the public health economy, which integrates economic, political, and social drivers of health. The authors highlight structural factors (e.g., gentrification, environmental racism) and propose interventions across multiple sectors. Their focus on liberation and community agency adds a psychosocial dimension, though individual capabilities receive less attention compared to systemic forces. The scope is expansive, sometimes to the point of overreach, as it seeks to unify diverse fields under one transdiscipline.

Assessment: Both manuscripts recognize health equity’s multidimensionality, but Sen’s theorizing is more balanced and comprehensive, addressing both outcomes and processes. Williams et al.’s broader scope is ambitious but occasionally lacks depth in individual dimensions.

2.4 Applicability and Practicality

Definition: How well do the authors connect their theoretical framework to practical interventions or policy implications?

• Sen:
  Sen’s manuscript is primarily theoretical, focusing on conceptual foundations rather than specific applications. He hints at policy implications—e.g., prioritizing resource allocation over healthcare rationing—but does not detail actionable strategies. His critique of proposals like “fair innings” suggests practical considerations (e.g., avoiding discrimination), but the emphasis remains on guiding principles rather than implementation.

• Williams et al.:
  PHL excels in practicality, linking theory to community-based action. Examples like community gardens, vaccination drives, and advocacy against gentrification demonstrate how liberation and the public health economy translate into praxis. The authors propose concrete tools—e.g., social mobilization, regulatory constraints, economic incentives—making their framework directly applicable. Their focus on horizontal and vertical integration ensures community voices shape interventions, enhancing relevance to real-world challenges.

Assessment: Williams et al. outperform Sen in applicability, offering a actionable roadmap for health equity. Sen’s work, while foundational, remains abstract, prioritizing theoretical clarity over practical guidance.

3. Preferred Manuscript and Rationale

Based on the analysis, Amartya Sen’s “Why Health Equity?” emerges as the preferred manuscript for theorizing health equity. Sen’s work excels in conceptual clarity, providing a precise, philosophically grounded definition that distinguishes health equity from related concepts. Its theoretical depth is unmatched, leveraging a cohesive capability framework and engaging critically with alternative theories. In terms of scope and multidimensionality, Sen offers a balanced, comprehensive approach that integrates health into broader justice concerns without losing focus. While weaker in applicability and practicality, this does not detract from its strength as a theoretical contribution, as the primary task is to conceptualize health equity rather than operationalize it.

Williams et al.’s “Public Health Liberation” is a commendable effort, particularly for its practicality and innovative scope. The introduction of the public health economy and liberation as organizing principles is bold and relevant, especially for addressing structural inequities in marginalized communities. However, its conceptual clarity suffers from the proliferation of new constructs, and its theoretical depth is less refined, reflecting an exploratory rather than fully developed framework. While its multidimensionality is ambitious, it occasionally sacrifices depth for breadth.

Sen’s manuscript provides the “why” of health equity—a foundational understanding essential for any subsequent action—whereas Williams et al. tackle the “how,” offering a transformative vision for practice. For the purpose of theorizing, Sen’s rigorous, coherent framework is superior, establishing a bedrock upon which practical approaches like PHL can build.

4. Conclusion

Both Sen’s “Why Health Equity?” and Williams et al.’s “Public Health Liberation” contribute significantly to the discourse on health equity, albeit from different perspectives. Sen’s work stands out for its clarity, depth, and theoretical sophistication, making it the preferred choice for a robust conceptualization of health equity within social justice. Williams et al.’s manuscript, while less polished theoretically, offers a dynamic, community-centered approach that complements Sen’s insights with practical strategies. Together, they suggest a synergy: Sen’s foundational theory paired with PHL’s actionable transdiscipline could form a comprehensive approach to both understanding and achieving health equity. For the specific task of theorizing, however, Sen’s manuscript remains the gold standard.