The Concept of Health
Disparities: Splitting Hairs
--or Crucial to Guide
Policy?
June 29, 2009
Academy Health
Paula Braveman, MD, MPH
Professor of Family & Community Medicine
Director, Center on Social Disparities in Health
www.ucsf.edu/csdh
©2000 The New Yorker Collection from cartoonbank.com. All rights reserved.
“The poor are getting poorer, but with the rich getting richer it all
averages out in the long run.”
What are “health disparities”?
No consensus

Disparities = differences, variations, inequalities
• Largely descriptive terms

NIH: “Differences in the incidence, prevalence, mortality, and
burden of diseases and other adverse health conditions that
exist among specific population groups in the U.S.”
• No further restrictions on the groups, no criteria
• All of epidemiology

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But we really mean: Health differences that are unfair in a
particular way
The term came into use in 1990s to refer to racial/ethnic
differences in health or health care, without being explicit
about why these differences deserve special attention
Lack of consensus on concept of
health disparities

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Health often equated with health care
Fine print in Healthy People 2010: “differences
that occur by gender, race or ethnicity, education
or income, disability, [urban vs rural location], or
sexual orientation” without mention of criteria
Internationally, “health inequalities” primarily
refers to socioeconomic differences although other
dimensions appear
• Whitehead: avoidable, unnecessary, unfair differences

But who decides what is avoidable, unnecessary, unfair? How?
Are all health differences unfair,
avoidable, and unnecessary?

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Skiers are more likely
to have arm/leg
fractures
Younger adults are
generally healthier
than the elderly
Female newborns have
lower birth weights
Male newborns have
higher birth weightspecific mortality
• Latinos were less likely to
receive pain meds for arm/leg
fractures; not due to language
or patient preferences
• 4-fold racial disparity in
maternal mortality
• Blacks & Latinos more
likely to live in “food deserts”
Are these “health disparities”?

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White women have a higher incidence of breast
cancer.
In most countries, women have longer life
expectancy than men.
Latina immigrants have better birth outcomes than
non-Latina white women.
Two affluent communities of similar racial/ethnic
composition. One has higher rate of disease X.
What if the causes are unknown?
• Compared with her/his European-American
(“white”) counterpart, an African-American
(“black”) baby is 2 to 3 times as likely:

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to have low birthweight
to be born prematurely
predicting infant mortality, child morbidity and
development, and adult chronic disease
• The causes of these disparities are not known
How do we decide what’s fair?
Ethics

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Distributive justice
Rawls: What action/policy would you choose
behind a “veil of ignorance”, not knowing if
you were born into a privileged family?
Need --not privilege-- should guide resource
allocation for health
• But it’s challenging to define need

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Valuing all persons equally
Equal opportunities to be as healthy as possible
Human rights principles give
guidance on what’s fair

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Economic & social rights to: health, education,
water, food, shelter, decent living standard,
benefits of progress…
All rights are indivisible and inter-connected
Right to health: right to achieve the highest
possible level of health
• We operationalize this as reflected by level of health
enjoyed by most socially privileged group

Governments are obligated to progressively
remove obstacles to realizing all rights
• particularly for those with more obstacles
Human rights principles:
Non-discrimination
• Governments obligated to end unfair discrimination -including de facto (unconscious, institutional)
discrimination – not just deliberate, inter-personal
• Governments obligated to remove obstacles to
realizing rights, particularly for groups with more
obstacles

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Women, children, disabled, stigmatized (e.g.HIV+)
Racial/ethnic, religious, tribal, or national origin groups
Those lacking basic rights (e.g., the poor, marginalized,
excluded)
What are health disparities based
on ethics-rights principles?

Potentially avoidable disparities --in health
or its determinants-- that systematically and
adversely affect socially disadvantaged
groups, i.e., those that have
• suffered discrimination, marginalization, or
exclusion
• greater social obstacles to realizing their rights
• e.g., de-valued racial/ethnic groups, women, the
poor, elderly/children, LGBT, disabled, HIV+
Defining health disparities to
guide policy & measurement

Differences in health --or its determinants-- that
are closely & systematically linked with social
advantage/disadvantage
• Social advantage/disadvantage: based on belonging to a
group with higher/lower social position (hierarchies
according to wealth, influence, prestige, acceptance)
• Adversely affect already disadvantaged groups, placing
them at further disadvantage on health
• Health disparities are particularly unfair because health
is needed to overcome social disadvantage

Potentially (plausibly) shaped by policy given
political will
Racial/ethnic disparities deserve
special priority

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Based on greater obstacles to realizing all
rights, including right to health
Compound disadvantage
Long history of brutal discrimination
(slavery, Jim Crow, legal segregation) &
persisting institutional racism (linking race
and class) denying equal opportunities to be
healthy
Concepts and measurement of
health disparities

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Measurement driven by concept: groups to be compared,
reference group, how compared & on what?
More than a technical matter
Based on values: It is about social justice.
• Ethics
• Human rights concepts reflect global consensus

Avoiding normative aspect may seem expedient but may
endangers efforts to achieve greater equity in health
• Provides opening to divert resources from social justice issue
• Value-free definition removes social justice from agenda for public
health information and hence policy
Questions for you
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Can we call a disparity an inequity if causes are
unknown?
Is it sufficient to know that the disparity:
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is systematically linked with social inequity? or
puts disadvantaged groups at further disadvantage on health?
Trade-offs between broadening scope beyond
racial/ethnic disparities (& risking diverting resources)
& benefits of having firm basis in values