Health systems of oppression: applying intersectionality in health systems to expose hidden inequities

Intersectionality is a useful lens to understand how inequities in health develop and are experienced. Intersectionality is both a theory and methodological approach that demonstrates how overlaying social stratifiers (e.g. gender, ableness, sexual orientation and identity) can result in mutually enforced vulnerabilities that render some groups at an advantage and others at a disadvantage (Bowleg, 2008; Nixon, 2019). For example, as described in Crenshaw’s (1989) work, the experience of Black women is not wholly captured by being Black or a woman alone. Rather, the intersection of being both Black and a woman interacts in ways that result in a unique experience unable to be explained by either single identity (Crenshaw, 1989). This process is dynamic and advantage/disadvantage is not dichotomous but on a continuum (Larson et al., 2016). Even though equity is one of the driving aims for a health system, indicators for performance, such as infant mortality rate (World Health Organization, 2010), are often measured at the population level, masking inequities. Such aggregate level analyses do not tell us where inequities in health outcomes might exist, what the root causes are, or how to address root causes of inequity (Larson et al., 2016). We use an intersectional approach to explore how health systems can perpetuate systems and structures of oppression and describe how an intersectional-informed approach can be used to understand and highlight inequities in health and health systems. This topic is particularly pertinent, as the ongoing COVID-19 pandemic highlights how health systems can entrench and perpetuate broader societal power hierarchies, resulting in differential and inequitable health outcomes (Ahmed et al., 2020). This commentary serves to start a conversation on how intersectionality and health systems are linked through illustrative examples.