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The goal of this article is to advance understanding and action on health inequities and the social determinants of health by introducing a framework for transformative change: the Coin Model of Privilege and Critical Allyship. First, I introduce the model, which explains how social structures produce both unearned advantage and disadvantage. The model embraces an intersectional approach to understand how systems of inequality, such as sexism, racism and ableism, interact with each other to produce complex patterns of privilege and oppression. Second, I describe principles for practicing critical allyship to guide the actions of people in positions of privilege for resisting the unjust structures that produce health inequities. The article is a call to action for all working in health to (1) recognize their positions of privilege, and (2) use this understanding to reorient their approach from saving unfortunate people to working in solidarity and collective action on systems of inequality.

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.

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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.

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.

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.

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?

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.

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.

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.

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.

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.

This reframing reverses who is presumed to be more expert on dismantling the inequity (i.e., from people on the top of the coin to people on the bottom), and whose thinking and behaviour need to change in order for the inequity to be dismantled (i.e., from people on the bottom of the coin to people on the top). Reframing the problem as the ineffective and unhelpful orientation of people in positions of unearned advantage allows new possibilities for action to come to light. Below I introduce several principles as an entry point for guiding such action, i.e., for practicing critical allyship.

An initial step is to recognize and resist the everyday ways that people on the top of a coin unintentionally strengthen, as opposed to dismantle, the coin; that is, the things we say or do that unwittingly reflect and therefore reproduce the system of inequality. A key step in this practice is to reject the dangerous and misguided urge to save people on the oppression side of the coin, driven by the irrational sense of expertise, entitlement and access [49]. Rather, the aim of critical allyship is to operate in solidarity with people on the bottom of the coin. This principle applies to students, researchers or clinicians developing health promotion programs for or conducting research with marginalized communities locally or globally [50], without understanding their personal relationship to the systems of inequality that marginalize these communities in the first place [51].

A starting point for resistance is naming and discussing privilege with others on the top of that coin to diminish oblivion (i.e., to see the gorilla) and collectively build capacity for change. Examples include straight people discussing how they benefit from and reproduce heteronormativity [57], able-bodied people considering the unearned advantages they receive from ableism [58], white people learning about their role in perpetuating racism [41, 59], or settlers exploring settler identity in the context of colonialism [60, 61], with careful attention to how these structures simultaneously intersect. Each of these systems requires deep learning and, moreover, unlearning of entrenched assumptions to guide individual and collective action for transformative social change [62].

There is also transformative potential in stepping back metaphorically. This is the invitation to listen more and speak less. Those in positions of influence can step back to reallocate power to people who have historically been pushed to the margins. This includes making room for - and recognizing as legitimate - the feelings, approaches, and worldviews of people on the bottom of the coin. This requires those on the top of coins to demonstrate humility regarding the assumed rightness of certain ways of doing, communicating, and thinking, and stepping back to make room for alternatives. 2351a5e196