The coin
There are norms, patterns and structures in society that work for or against certain groups of people, which are unrelated to their individual merit or behaviour. Put another way, there are (often invisible) systemic forces at play that privilege some social groups over others, such as sexism, heterosexism, racism, ableism, settler colonialism, and classism [14]. These unfair social structures have profound effects on health, producing inequities in morbidity and mortality.
Racism is well demonstrated to adversely affect the health of non-white people through interconnected structural, institutional, cultural and psychosocial pathways [15, 16]. For instance, there is a breadth of evidence in the American context demonstrating that people who are racialized receive lower quality health services and are less likely to receive routine medical procedures than white Americans [17]. Racism and its interconnection with colonialism have created profound health inequities for Indigenous Peoples, including lower life expectancy (by more than 5 years) than the non-Indigenous population in the United States [18,19,20]. Women and girls have worsened health outcomes, diminished capacity to realize health-related human rights, and reduced access to healthcare, which are related to sexism, and its intersections with class, race and ability [21,22,23]. People who are gay, lesbian or bisexual face health inequities related to heteronormativity and homophobia [24, 25]. Furthermore, there is worsened health among transgender people due to cisnormativity and transphobia, which is exacerbated by other systems of oppression [23, 26–27]. A study in the Canadian province of Ontario found that one in ten trans people who had accessed an emergency room had been refused care or had care terminated prematurely because they were trans, and 40% had experienced discriminatory behaviour from a family doctor [27]. A final example is health disparities among people with disabilities related to ableism and its intersections with other systems of inequality [28, 29]. Census data from 2015 demonstrated that nearly 14% of Australians with a disability reported disability-based discrimination in the previous year; that disability-based discrimination was more common among people who were unemployed or poor; and, that disability-based discrimination was associated with higher levels of psychological distress and poorer self-reported health [29]. These systems of inequality are bad for health.
In the Coin Model, each system of inequality is conceptualized as a coin. Coins do not reflect the individual behaviour of good or bad people. Rather, they are society-level norms or structures that give advantage or disadvantage regardless of whether individuals want it or are even aware of it. Each coin represents a different system of inequality.
These social structures, or coins, give unearned advantage or disadvantage according to one’s relationship to that particular system of inequality. For instance, one may consider the coin (or system of inequality) of heterosexism. Heterosexuality is romantic or sexual attraction to people of the opposite sex. Heterosexism, a dominant norm in many societies, views being heterosexual as the only normal and right way to be. People who happen to fit this norm because they are straight (i.e., heterosexual) enjoy advantages from this social structure. For instance, they can openly express affection without fear of discrimination or violence. They see their way of life validated and valued through its regular, positive, and default position as the normal way of being reflected in legal frameworks and popular culture. However, straight people did not choose to be straight; they just are. They did not earn this advantage; rather, they lucked into it by their natural preference for whom they love being in alignment with this broader social norm. They likely did not ask for these benefits, but they receive them all the same. They may not even be aware that they are receiving unearned advantage, but they receive it nonetheless [30].
Conversely, people who are not straight do not enjoy this freedom from discrimination and violence, or the sense of inclusion and belonging that results from this social structure. People who are not straight, such as people who identify as gay, lesbian, bisexual, asexual, or two-spirit, did not choose to be that way; they just are. However, their natural preference for whom they love is not in alignment with the dominant norm of heterosexism and, as such, they receive unearned disadvantage. They did nothing to earn it, but they receive it nonetheless. Furthermore, while unearned advantage can be difficult to see, unearned disadvantage is often highly visible to those who experience it.
The bottom and top of the coin: oppression and privilege
It is the same social structure, or coin, that gives unearned disadvantage to some and unearned advantage to others. Groups of people who are disadvantaged by this social structure are viewed as being on the bottom of the coin (see Fig. 1). In this model, I call this side of the coin oppression. Because of the dire health effects resulting from this unfair disadvantage, these are the groups commonly targeted in health promotion research and interventions. The names for these groups are many and familiar, including marginalized populations, disadvantaged groups, vulnerable communities, high-risk groups, priority neighbourhoods, or hard-to-reach populations.
Other groups of people receive advantage from these same social structures, and are viewed as being on the top of the coin. These groups receive benefits from the structures that others do not, which they did not earn. Rather, they receive the benefit because they luck into being in alignment with the norms of that particular social structure. In this model, I call the position on the top of the coin privilege.
Terms used to describe groups of people who enjoy unearned health benefits as a result of systems of inequality are uncommon and hard to imagine (e.g., unfairly advantaged groups, free-lift populations). To view those on the top of the coin as “normal” or “average patients” is erroneous since, by definition, the top of the coin represents people who are the recipients of unearned and unfair benefits because their way of being is valued over others. The goal is not to move people from the bottom of the coin to the top, because both positions are unfair. Rather, the goal is to dismantle the systems (i.e., coins) causing these inequities.
Drawing attention to the top of the coin is important because inequity is relational: the bottom of the coin is disadvantaged compared to the top. Yet, issues of health equity are often framed exclusively as problems facing people on the bottom of the coin. Disappearing the top of the coin, and often the coin itself, functions to maintain the status quo because what one frames as the problem sets the universe of conceivable actions to address it. When the problem is framed as challenges faced by the members of a “vulnerable group” (i.e., bottom of the coin), then potential solutions will focus exclusively on interventions to address their issues. Should actions address the needs of these groups? Of course; these responses are deeply important for redressing existing inequities. However, the bottom of the coin is commonly framed as the entire story of health equity as opposed to just one part. If the problem was viewed not only as the bottom of the coin, but also the coin itself (i.e., the unjust social structure that gives unearned disadvantage to people on the bottom), then a different set of solutions could follow, such as changes to policy and law to create safeguards against discrimination produced by the system of inequality. Indigenous physician and public health leader, Marcia J. Anderson, succinctly captures this point as follows:
“From now on instead of ‘vulnerable people’ I'm going to use the phrase ‘people we oppress through policy choices and discourses of racial inferiority.’ It's a bit longer but I think will help us focus on where the problems actually lie.” [31]
For instance, the coin of ableism reflects the social structure that discriminates against disabled people in favour of people who fit a socially-constructed norm of able-bodiedness [32]. In an ableist worldview, there is a particular version of ability that is assumed to be normal or natural (top of the coin), and people who cannot meet this expectation (bottom of the coin) are viewed as a problem who should strive to become, or assimilate to, the norm. Ableism views disability as a mistake or failing rather than a simple consequence of human diversity, like sexual orientation or gender.
Consider the different solutions that become imaginable depending on whether one views the problem as the bottom of the coin (i.e., disabled people) or the coin itself (i.e., ableism). Solutions addressing the bottom of the coin strive to support disabled people to achieve the norm of able-bodied people, including medical care and rehabilitation to fix disability within the body. Conversely, if one views the problem as the unfair social structure of ableism, then the cause of disability shifts: instead of being located within an individual’s body, disability is understood as resulting from the social, attitudinal and political environment. Responses become focused on social change to achieve equity for people with disabilities in the same light as equity for other disadvantaged groups where prejudice, segregation, and inaccessibility are viewed as the problem. Responses might focus on rights-based approaches aligned with the United Nations Convention on the Rights of Persons with Disabilities. Actions would shift from focusing on disability as a mistake to instead celebrating difference by creating flexible systems (e.g., through policies, the built environment) that enable and liberate as opposed to disable and exclude.
Problematizing the coin of ableism also shines a spotlight on the profoundly disabling effects of stigmatizing attitudes commonly held by able-bodied people. In many cases, such effects are unintended and unknown to those reproducing them, but profoundly impactful all the same, which brings us to the top of the coin.
Seeing the gorilla: recognizing the effects of invisiblizing privilege
The coin of settler colonialism in the context of Canada provides another useful illustration. If the coin is settler colonialism, then the group receiving unearned disadvantage on the bottom of that coin is Indigenous Peoples. Since the Idle No More movement and 2015 report of the Truth and Reconciliation Commission of Canada, the history and legacy of colonization are starting to be recognized within Canadian society [33, 34]. For instance, there is greater attention to the ongoing, devastating effects of Indian Residential Schools on Indigenous Peoples, the harmful effects of the Government of Canada’s Indian Act, and the rights-violations embedded in the inequitable provision of public funding to ensure basic determinants of health (e.g., clean drinking water, quality primary education) within Indigenous communities. These examples draw attention to the coin (i.e., settler colonialism) as the source of profound health inequities between Indigenous and non-Indigenous people in Canada. The problem has been relocated from Indigenous People (the bottom of this coin) to the structures (the coin) that create the conditions that produce unearned and unfair disadvantages. The growing ability to see, and thereby devise solutions to address, the coin is an important marker of progress toward dismantling this inequity.
But Indigenous People and settler colonialism are not the complete picture. Similarly, disabled people (bottom of the coin) and ableism (the coin), are not the complete picture. What about the people on the tops of these coins? Who are they? What is their role in dismantling, or as is often the case, unintentionally strengthening the coin?
A key task for people who find themselves on the top of a coin is to see the gorilla; that is, to understand that there is a coin, that it has two sides, and that they occupy the position of unearned advantage (i.e., privilege) on the top. For instance, if Indigenous People are on the bottom of the coin, it is non-Indigenous people (often referred to as settlers) who receive unearned and unfair advantage from these same structures. Seeing the gorilla in this instance means developing the capacity to ask and answer questions such as, “In which ways did I benefit from settler privilege today?” and “In what ways did my actions today reflect and thereby reinforce the coin of settler colonialism?”
In many cases, people on the top of a coin did not ask for the unearned advantage that they receive. However, people are rarely on the top of the coin because of merit or worth (commonly referred to as the myth of meritocracy [35]). Rather, they are there, by definition, because they happen to be able-bodied, settlers, white, straight, cisgender, or other aspects of their social identity that they did not choose, but which nonetheless align with historic planes of domination and subordination [13].
Just as the disadvantage received by people on the bottom of the coin is unearned and unfair, so too, the advantage received by people on the top of the coin is unearned and unfair. However, these opposite effects of the coin are not evenly understood.
The contradiction of who holds expertise vs who holds power regarding systems of inequality
The unfair disadvantage associated with the bottom of the coin is frequently in plain view – to clinicians and researchers working to address these challenges, and especially to people on the bottom of the coin themselves who may confront these disadvantages daily. Regardless of whether people on the bottom of the coin are fluent in the language of anti-oppression, they typically are expert in the many ways that the coin operates to create disadvantage, dehumanization, lack of safety and social exclusion. Moreover, it is these groups who have historically led movements to dismantle the coins, such as Indigenous Peoples leading movements to redress the harmful effects of colonization on First Peoples and the environment, or Black people leading anti-racism civil rights movements.
However, the unearned advantage associated with being on the top of the coin is often invisible – in health promotion interventions, in health equity research, and especially to the people themselves who occupy positions on the top of coins. Some have argued that the obliviousness of people about their positions of privilege is a key strategy required to sustain the hegemony of systems of inequality [36]. Learning to see the gorilla is a strategy for becoming less oblivious and less harmful.
Lack of awareness about the top of the coin has serious implications for meaningfully addressing health equity. This is because lack of recognition of the societal influences that have helped elevate people on the top of coins to reach their professional, economic or social positions commonly leads those same people to presume that they are there exclusively because of their individual merit. Put another way, where privilege is unchecked, it can lead to an irrational sense of entitlement, expertise and access. It then seems logical and, indeed, a moral imperative for those on the top of the coin to be guided by an altruistic urge to save or fix people on the bottom of the coin. However, this logic no longer holds when one considers who possesses expertise regarding the coin and its effects; that is, people on the bottom of coins.
Furthermore, invisibilizing the top of the coin allows people in positions of privilege to view themselves as unconnected to, or outside of, the systems of inequality they are trying to address, as opposed to understanding their direct relationship to people on the bottom of the coin. Instead of understanding their complicity within systems of inequality, disappearing the top of the coin allows people on the top to frame their role in health equity work as neutral, selfless and altruistic. This positioning logically leads to action that (exclusively) assists people on the bottom of the coin as opposed to targeting oppressive systems that are bad for all.
Within the health sphere, the people who typically hold the power to allocate resources, design programs, and draft policy to address the needs of people on the bottom of the coin often find themselves on the top of multiple coins. But who are the real experts in understanding how the coin operates in society? When people in privilege do not realize the powerful implications of that position, they may unwittingly – and with the best of intentions – devote themselves to trying to help people on the bottom without ever understanding: (1) the impact of the coin on their own individual position, (2) how this lack of understanding vastly compromises their insight about the oppressive social structure, and (3) how this lack of insight can lead to actions that serve not to dismantle the coin, but to strengthen the status quo. For instance, the assumed expertise of people on the top of the coin to solve the problems of inequity becomes reinforced, while the assumed neediness and lack of expertise of people on the bottom of coins is further entrenched. Materials resources (e.g., salaries, grant funding) to address health equity commonly flow to people on the top of the coin to design and administer programs for people on the bottom of the coin, thus reinforcing inequities.
In summary, lack of awareness about one’s position on the top of coins is dangerous for health equity. Indeed, the invisibility of privilege is central to the functioning and sustainability of the system of inequality. Invisiblilizing the top of the coin, and frequently the coin itself, ensures that the coin remains strong. This is the gorilla, and why movement toward dismantling systems of inequality requires everyone, and especially people on the top of coins, to learn how to see the gorilla.
Recognizing the intersecting nature of multiple coins
A single coin does not represent all privilege or all oppression. Rather, each coin represents a specific system of inequality (e.g., sexism, racism, ableism). Each person typically occupies the position on the top of some coins and the bottom of other coins at the same time. A common pattern is for people to have a well-developed understanding of the system of inequality for which they find themselves on the bottom and, perhaps, frustration, anger or sadness that this unjust system is not better understood by people on the top of that same coin. This insight can be helpful for then considering one’s (often limited) knowledge about the systems of inequality where they find themselves on the top.
Furthermore, it is important to recognize that while each coin represents a different system of inequality, the coins do not operate in isolation. Rather, the coins intersect to create complex inter-relating systems of inequality (see Fig. 2). The result is not additive; finding oneself on the same side of two coins does not mean that one is twice as privileged or twice as oppressed. Rather, intersecting systems of inequality produce new and complex patterns of advantage and disadvantage. The relevance and impact of these positions varies according to context, and so one’s positions on these multiple coins need to be analyzed together. The term, intersectionality, was introduced by legal scholar and critical race theorist, Kimberlé Crenshaw, and further understood as the matrix of domination by Black feminist scholar, Patricia Hill Collins, in order to characterize the unique forms of oppression faced by women who are Black [37, 38]. Intersectionality has been taken up widely, including within the health sphere [39, 40].
Analysis requires the precision of clarifying one’s position on the top or bottom of each particular coin, with special attention to those coins for which one is on top, and how these individual positions may amplify each other in different contexts. Importantly, not all coins are the same size; that is, different systems of inequality will matter more or less in different contexts, and depending on their intersection with other patterns of inequality.
Another key insight offered by an intersectional analysis is how experiences of oppression in one system of inequality do not negate positions of privilege in others. For instance, a white person who is poor may clearly understand the oppressive effects of classism, but may not also appreciate the ways they simultaneously benefit from being on the top of the coin of racism. A racialized person who is considered able-bodied may understand the devastating effects of racism while being unaware of how their ableist privilege serves to regularly give them unearned advantage. An intersectional analysis reminds us that the effects of these different positions cannot be understood through a mathematical approach whereby the position on the bottom of one coin cancels out the position on the top of another. This is how even the most articulate activists on certain systems of inequality can unintentionally strengthen other coins where they find themselves on top because of their unrecognized positions of privilege, i.e., their lack of capacity to see that particular gorilla.
This is not about innocence or guilt
Discussions of privilege can lead to faulty assumptions of innocence, and counterproductive attention to guilt. The coin model is premised on an analysis that rejects both of these unhelpful patterns.
Framing people on the top of the coin as oblivious about their unearned privilege does not equate to innocence among those individuals. For the most part, people within the health sphere who are in positions of privilege do not intend to cause harm; however, these coins were created very intentionally by people on the top of the coin. These systems were designed to oppress, and they are sustained, intentionally by some and unintentionally by others, who are on top of the coin. It is not the intent of one’s actions that matters but the impact, and the impact of oblivion among people on the top of the coin can be deeply harmful, dehumanizing and violent to people on the bottom of the coin. Indeed, these systems of inequality are harmful to whole societies because they diminish the contributions and talents of people on the bottom of coins through the barriers they face.
Another common narrative is the feeling of guilt among people when considering the unearned benefits they receive because of being on the top of a coin. Feelings of guilt can lead to discomfort, distancing from the issue, denial, or intellectual paralysis. In the context of racism, white academic Robin DiAngelo calls this phenomenon “white fragility” [41]. Guilt can become the primary focus of discussion and analysis among people who share positions on the top of a coin. However, the coin model invites analysis of how focusing on guilt serves to strengthen vs dismantle systems of inequality. Guilt leads to feelings of distress among people through reflecting on the unearned advantages and free lifts that make their lives easier. This distress must be understood in contrast to the (often daily) distress, dehumanization, and violence experienced by people on the bottom of the coin. Furthermore, focusing on the guilt born of discovering unearned benefits serves to centre the needs and feelings of people on the top of the coin, which reinforces the coin by crowding out the needs and feelings of people on bottom. In the words of the Black, lesbian poet and philosopher, Audre Lorde:
“Guilt is not a response to anger; it is a response to one’s own actions or lack of action. If it leads to change then it can be useful, since it is then no longer guilt but the beginning of knowledge. Yet all too often, guilt is just another name for impotence, for defensiveness destructive of communication; it becomes a device to protect ignorance and the continuation of things the way they are, the ultimate protection for changelessness.”[42]
If guilt is an unproductive strategy for people on the top of the coin who wish to dismantle inequities, then what might be alternatives? A more productive strategy is to recognize feelings of guilt, and swiftly reframe guilt as responsibility deriving from complicity [43]. Embracing responsibility gives rise to action to resist the dominant norms that sustain systems of inequality, which I refer to as practicing critical allyship.