CENTER ON SOCIAL DISPARITIES IN HEALTH
University of California, San Francisco
The concept & measurement of health
inequalities and health equity: not merely
a technical matter
International Society for Equity in Health
Cartagena, Colombia
September 26, 2011
Paula Braveman, MD, MPH
University of California, San Francisco
Professor of Family & Community Medicine
Director, Center on Social Disparities in Health
CENTER ON SOCIAL DISPARITIES IN HEALTH
University of Calif ornia, San Francisco
The concepts & measurement of health
inequalities and health equity– not merely a
technical matter
 Does everyone agree?
 What is at stake?
 An approach based on ethical and human rights
principles
“The poor are getting poorer, but with the rich getting
richer it all averages out in the long run.”
©2000 The New Yorker Collection from cartoonbank.com. All rights reserved
CENTER ON SOCIAL DISPARITIES IN HEALTH
University of Calif ornia, San Francisco
What are “health inequalities”?
 Differences, variations: descriptive terms
 Most official U.S.A. definitions refer only to
differences between unspecified groups
 But we really mean: Health differences that are
unfair (in a particular way)
 Whitehead: unfair, avoidable, and unjust
 But notions of fairness, avoidability, and justice vary
CENTER ON SOCIAL DISPARITIES IN HEALTH
University of Calif ornia, San Francisco
Are all health differences unfair?
 Many women have
obstetric problems;
men do not
 Arm/leg fractures
more likely in skiers
than non-skiers
 Wealthy people in
Manhattan have some
health problems that
wealthy people in
Hollywood do not
 Younger adults are
generally healthier
than the elderly
 Some claim that
any avoidable
health difference is
unfair
 Who determines
what is avoidable?
CENTER ON SOCIAL DISPARITIES IN HEALTH
University of Calif ornia, San Francisco
What if the causes are not known?
 In the USA, compared with European-American
(“White”) newborns, African-American (“Black”)
newborns are 2 to 3 times as likely:
 to have low birth weight
 to be born prematurely
 which predict infant
mortality, childhood
disability and development,
and adult chronic disease
 The causes are not known
 Can we call it unfair?
CENTER ON SOCIAL DISPARITIES IN HEALTH
University of Calif ornia, San Francisco
Other challenges: Which groups?
 The U.S. National Institutes of Health (NIH) has a
new institute on minority health and health
disparities (NIMHD).
 Should NIMHD prioritize health of:
 Veterans?
 People with autism?
 People with rare but catastrophic diseases?
 Higher incidence of breast cancer among White
women?
 Shorter life expectancy among men?
CENTER ON SOCIAL DISPARITIES IN HEALTH
University of Calif ornia, San Francisco
Other challenges: Individuals v. groups
 A few researchers (then in leadership roles at WHO)
once proposed that health inequalities should not be
measured by comparing health of pre-selected social
groups, e.g., rich - poor
 Because it pre-judges causality, obstructing comprehensive
inquiry into causes
 Their approach: compare individuals (not groups) on
health only, then seek explanatory variables
 During their tenure, WHO ended an initiative providing
technical assistance to countries to collect & analyze health
data according to markers of social position
 Removed fairness & justice from the agenda for health
monitoring
CENTER ON SOCIAL DISPARITIES IN HEALTH
University of Calif ornia, San Francisco
Other challenges: the reference group for a health
equity comparison
 Some propose using the average as the reference
group, or the healthiest, regardless of their social
characteristics
 Active dispute now in some U.S. public health agencies
 What is wrong with using the population average –or
the healthiest-- as the reference group?
 Average underestimates inequalities where a higher %
of population are disadvantaged
 Many reasons –including biologic--for healthiest group
to be healthiest
CENTER ON SOCIAL DISPARITIES IN HEALTH
University of Calif ornia, San Francisco
Human rights principles provide guidance to
address these challenges
 The right to achieve the highest attainable standard
of health
 Rights to: education, living standard adequate for
health, benefits of progress
 All rights are inter-connected and indivisible
 Ratifying human rights agreements obligates
governments to progressively remove obstacles to
realizing all rights
 Particularly for groups who have more obstacles
CENTER ON SOCIAL DISPARITIES IN HEALTH
University of Calif ornia, San Francisco
Relevant human rights principles, e.g.:
Non-discrimination and equality
 All persons have equal rights and should be able to
realize all their rights without discrimination
 Including de facto (unconscious, institutional)
discrimination – not just deliberate, inter-personal
 Prohibit policies with either intent or effect of
discrimination
 Affirmative action is needed to achieve equal rights
for vulnerable groups
CENTER ON SOCIAL DISPARITIES IN HEALTH
University of Calif ornia, San Francisco
Human rights principles:
Non-discrimination and equality
 Specifies vulnerable groups: defined by race or ethnic
group, skin color, religion, language, or nationality;
socioeconomic resources or position; gender, sexual
orientation or gender identity; age; physical, mental, or
emotional disability or illness; geography; political or
other affiliation
 Implicit: vulnerability due to history of discrimination or
marginalization, lower social position
A rights-based definition of health inequality
 A health difference closely linked with social or economic
disadvantage
 Health disparities adversely affect groups of people who
have systematically experienced greater social or economic
obstacles to health based on their
 racial or ethnic group; religion;
socioeconomic status; gender;
mental health; cognitive, sensory, or physical disability;
sexual orientation or gender identity;
or other characteristics historically linked
to discrimination or exclusion
A rights-based definition of health inequalities
 Not all health differences -- or even
all health differences warranting attention
 A particular subset of health differences
that reflect social injustice
 Plausibly avoidable, systematic
health differences adversely
affecting a socially
disadvantaged group
 May reflect social disadvantage –
but in any case put already disadvantaged
groups at further disadvantage
with respect to their health
CENTER ON SOCIAL DISPARITIES IN HEALTH
University of Calif ornia, San Francisco
Challenges addressed: Burden of proof regarding
causation
 The causes of many important health inequalities
(e.g., racial disparities in low birth weight,
premature birth or in stage-specific breast cancer
survival) are unknown
 Regardless of causes, health inequalities are unfair
because they put already disadvantaged groups at
further disadvantage on health
 Health inequalities are further obstacles to achieving
rights
CENTER ON SOCIAL DISPARITIES IN HEALTH
University of Calif ornia, San Francisco
Challenges addressed: Groups or individuals?
Which groups?
 Compare groups with different levels of social
advantage: resources, power, prestige/acceptance
 Human rights principles define the groups
 Racial/ethnic, religious, or tribal
 Socioeconomic (income/wealth, education, occupation)
 Gender, gender identity, sexual orientation, age, mental or
physical disability/illness, geographic
 Implicit: groups that have historically experienced
discrimination or marginalization
 Appropriate groups verifiable based on evidence of
wealth, power (e.g., high political/executive office),
social inclusion (e.g., hate crime victims).
CENTER ON SOCIAL DISPARITIES IN HEALTH
University of Calif ornia, San Francisco
Measurement challenges: The reference group
 The most socially privileged group (greatest power,
wealth, prestige) , e.g.,
 High income/wealthy individuals, households, or
neighborhoods
 Most privileged racial/ethnic group
 Indicates what should be possible for all groups (the
“highest attainable standard of health”)
 The population average is too low a standard, especially
where large proportions are disadvantaged
 The healthiest group may be healthiest for reasons not
reflecting social justice
CENTER ON SOCIAL DISPARITIES IN HEALTH
University of Calif ornia, San Francisco
Contributions of a human rights framework
 Addresses de facto discrimination/exclusion
 Sets benchmark at highest attainable standard of
health
 Entitlement v. charity
 Addresses multiple dimensions of material and social
deprivation and disadvantage
 Poverty as well as race-based and other discrimination and
their physical and psychosocial consequences
 Supports addressing inequalities in social determinants of
health (rights to education, living standard adequate for
health, social participation…)
 Reflects global consensus on values and concepts
CENTER ON SOCIAL DISPARITIES IN HEALTH
University of Calif ornia, San Francisco
Concepts and measurement of health inequalities
and health equity: not just a technical issue
 Based on values
 Equity is the ethical principle underlying
a commitment to reduce inequalities
 Health inequalities are the metric by
which health equity is assessed
 Human rights principles can guide
analysis, measurement, and action
 Implications for policy agendas,
resource allocation, & accountability
 Inherently political