I was living in Costa Rica, working for the largest mammography equipment manufacturer in the world, when a book rearranged how I think about equity.
It wasn’t a healthcare white paper. It was The Blue Sweater by Jacqueline Novogratz. She writes about dignity, about proximity, about the arrogance of assuming you know what people need without listening. She makes the case that markets can be powerful tools for equity, but only if they’re designed with, not for, the communities they aim to serve.
That distinction hit me hard. I’d already spent years inside large medtech companies and high-growth environments. I’d launched products, led global teams, navigated M&A, and sat in rooms where capital allocation decisions were made. I understood innovation pipelines and regulatory strategy. I knew how the system worked.
But I hadn’t fully interrogated who the system was built for.
I remember sitting in a bar in Costa Rica one evening with a friend, a local professional who’d grown up there. We were talking about healthcare systems, what works, what doesn’t. On paper, Costa Rica’s universal healthcare system looks like a triumph. In many ways, it is. Life expectancy is high. Primary care is strong. Preventive services are embedded in communities.
But over drinks, he said something that stuck with me: “Equity here isn’t about having the newest machine. It’s about making sure no one is invisible.”
Invisible.
That word lodged itself in my brain.
In the U.S., we define equity through a lens of advanced capability. Do you have access to the latest imaging modality? The newest biologic? The best specialist? Equity conversations often center on bringing high-end innovation to underserved communities.
In many parts of the world, equity is far more fundamental. It’s potable water in a clinic. It’s a functioning ultrasound machine. It’s transportation to a hospital that doesn’t require a family to choose between a medical bill and feeding their children.
That conversation, layered on top of Novogratz’s framework, forced me to widen my aperture.
I looked at the hospitals I was visiting in the U.S. Full of cutting-edge equipment. Some rooms upgraded devices that were still clinically viable because newer versions had hit the market. Then I thought about facilities I’d seen elsewhere, where basic screening tools were missing entirely, where non-communicable diseases weren’t managed because diagnostics simply weren’t available.
This wasn’t a technological issue. It was structural.
The uncomfortable truth: I’d been part of a system that optimized for margin, scale, and shareholder return. That’s not inherently wrong. Innovation requires capital. Companies need to grow. I’ve spent 25 years building, scaling, and leading in that environment. I understand it deeply, and I respect what it enables.
But I also know how decisions get made.
I know how portfolio prioritization works. I know how markets are segmented and deemed “attractive” or “non-core.” I know how global strategies often translate into “U.S. first, Europe next, maybe the rest later.” I’ve seen how women’s health, especially outside of fertility and oncology, gets deprioritized because the ROI timeline doesn’t fit a traditional investment model.
That’s not malice. It’s math.
But math, when left unchecked by moral imagination, can codify inequity.
Novogratz writes about patient capital, the idea that solving complex problems requires time horizons and commitment that don’t always align with quarterly returns. Sitting in Costa Rica, watching a healthcare system function differently, I began to see that health equity in the U.S. and health equity globally aren’t even part of the same conversation.
In the U.S., equity often means reducing disparities within a high-resource system. Closing racial gaps in maternal mortality. Ensuring women with dense breast tissue receive appropriate follow-up imaging. Expanding insurance coverage.
Globally, equity can mean building the floor before you debate the ceiling.
Both matter. But conflating them obscures the work.
When I came back to the U.S., I couldn’t unsee any of it. I couldn’t unsee the equipment I’d personally rolled into dumpsters to make room for new inventory while women in Costa Rica’s eastern region were dying of breast cancer because the only mammography machine had been broken for years. I couldn’t unsee the way “target populations” and “penetration curves” sanitized decisions that determined whose lives represented a viable market. I couldn’t unsee the distance between the system’s language and its impact.
Because equity isn’t just about distribution of resources. It’s about distribution of power.
Who decides what gets built? Who decides what gets funded? Who decides which lives represent a viable market? If the people making those decisions have never stood in a clinic where the equipment doesn’t exist, have never watched a family choose between a medical bill and school fees, have never seen what a functioning ultrasound machine means to a community that’s never had one, then the math will keep producing the same outcomes. Not because anyone intended harm, but because the aperture was never wide enough to see it.
Living abroad sharpened that for me permanently. Wealth looked different. Community looked different. Measures of success looked different. And yet the fundamental desire, to be healthy, to care for your family, to have agency over your body, was universal. The systems failing women weren’t failing because the desire wasn’t there. They were failing because the design never accounted for it.
After 25 years in this industry, I’ve been in enough rooms to know that change doesn’t happen because we write another policy paper. It happens when leaders are willing to widen their lens, challenge their own assumptions, and design for those who have historically been invisible.
That book didn’t give me answers. It gave me a better question:
Who, exactly, are we building this for?