HEALTH EQUITY AND SOCIAL JUSTICE: DEFINITIONS
HEALTH EQUITY I
“[Health equity is] the absence of systematic and potentially remediable differences in
one or more aspects of health across populations or population groups defined socially,
economically, demographically, or geographically.”
Source: The International Society for Equity in Health
HEALTH EQUITY II
[Health equity is] “the absence of systematic disparities in health (or in major social
determinants of health) between groups with different levels of underlying social
advantage or disadvantage—that is wealth, power, or prestige. Inequities in health put
groups of people who are already social disadvantaged (for example, by virtue of being
poor, female, and/or members of a disenfranchised racial, ethnic, or religious group) at
further disadvantage with respect to their health….Equity is an ethical principle; it also is
consonant with and closely related to human rights principles. Assessing health equity
requires comparing health and its social determinants between more and less advantaged
groups. These comparisons are essential to assess whether national and international
policies are leading toward or away from greater social justice in health.”
Source: Paula Braveman and Sophia Gruskin, “Defining Equity in Health,” Journal of
Epidemiology and Community Health 57 (2003): 258.
HEALTH INEQUITY I
Health inequity refers to differences in population health status and mortality rates that
are systemic, patterned, unfair, unjust, and actionable, as opposed to random or caused by
those who become ill.
Source: see Margaret M. Whitehead, “The Concepts and Principles of Equity and
Health,” 22(3) International Journal of Health Services (1992): 429-445.
HEALTH INEQUITY II
Health inequity refers to “unfair or unjust differences in health determinants or outcomes
within or between defined populations.”
Source: Alex Scott-Samuel, 2009.
Comment
These definitions suggest that the root causes of health inequity derive from fundamental
social disadvantage (e.g., the ability or lack of ability to influence investment and social
policy), based on imbalances in political power or privilege. The implications are that
eliminating the inequity requires changing the conditions, structures, and systems of
privilege that produce inequity, rather than merely treating its consequences, through
programs or social services.
Why should we care about health equity? “…Health [is] a special good, which has both
intrinsic and instrumental value….Health is regarded as being critical because it directly
affects a person’s well-being and is a prerequisite to her functioning as an agent.
Inequalities in health are thus closely tied to inequalities in the most basic freedoms and
opportunities that people can enjoy.”
Source: Sudhir Anand, “The Concern for Equity in Health,” in Sudhir Anand, et al. (eds)
Health, Ethics and Equity (Oxford University Press, 2004): 16.
“Health equity cannot be concerned only with health, seen in isolation. Rather, it must
come to grips with the larger issue of fairness and justice in social arrangements,
including economic allocations, paying appropriate attention to the role of health in
human life and freedom. Health equity is most certainly not just about the fair
distribution of health.”
Source: Amartya Sen, “Why Health Equity,” in Anand, p.21.
HEALTH DISPARITIES
Health disparities are merely variations or differences in health between groups of people
that do not specify which differences matter.
Comment
According to Olivia Carter-Pokras, “Health disparities should be viewed as [the result of]
a chain of events signified by a difference in: 1) environment, 2) access to, utilization of,
and quality of care, 3) health status or 4) a particular health outcome that deserves
scrutiny. Such a difference should be evaluated in terms of both inequality and inequity,
since what is unequal is not necessarily inequitable.”
Source: “What Is a ‘Health Disparity’” Public Health Reports 117 (September-October,
2002): 426
“The terms ‘health inequalities’ and ‘health disparities’ are widely used as a concise
substitute for more precise terminology such as ‘social inequalities in health,’ which can
be cumbersome…”
Source: Paula Braveman, “Measuring Health Inequalities: the Politics of the World
Health Report, 2000,” in Health and Social Justice: Politics, Ideology, and Inequity in
the Distribution of Disease, Richard Hofrichter, ed. San Francisco: Jossey-Bass, 2003:
306.
NACCHO’s Health Equity and Social Justice Strategic Direction Team prefers not to use
the term disparities since disparities can refer to any difference in health status, without
specifying the kinds of differences that might be important. Health equity, as NACCHO
uses it, refers to fairness in the distribution of resources and the freedom to achieve
healthy outcomes between groups with differing levels of social disadvantage.
SOCIAL DETERMINANTS OF HEALTH
“Social determinants of health are the economic and social conditions that influence the
health of individuals, communities, and jurisdictions as a whole. [They]…determine the
extent to which a person possesses the physical, social, and personal resources to identify
and achieve personal aspirations, satisfy needs, and cope with the environment…Social
determinants of health are about the quantity and quality of a variety of resources that a
society makes available to its members. These resources include—but are not limited
to—conditions of childhood, income, availability of food, housing, employment and
working conditions, and health and social services.”
Source: Dennis Raphael, “Introduction to the Social Determinants of Health,” in Social
Determinants of Health: Canadian Perspectives, Dennis Raphael, ed. Toronto: Scholars
Press, 2004.
SOCIAL JUSTICE
Two central features define social justice—social and democratic equality. The first,
social and economic equality, is based on recognition of common human interests.
According to Philip Green, in Equality and Democracy, equality refers to “the systematic
treatment of representative persons viewed in the abstract as members (subjects) of some
organized social whole, rather than with the treatment of particular individuals with
unique, individual needs and interests…..’Similar treatment for all who find themselves
in relevantly similar circumstances’ is therefore the general definition of social justice as
equality.” In this respect, social justice demands an equitable distribution of public goods
(mass transportation, access to quality schools, clean water, etc), institutional resources
(e.g., social wealth), and life opportunities. (Beyond distributional questions, economist
Amartya Sen in Inequality Reexamined defines a just society as one that ensures the
development and the capacities of all of its members.) Equality, more than a formal
category such as equality before the law or equal opportunity, means equalizing the
circumstances of life over which people have no control, and access to conditions that
enable people to realize themselves.
The second feature concerns democracy (political equality), which refers to enhancing
the collective empowerment of (giving voice to) whole classes of people—women,
minorities, workers, youth, the aged, and so on, along with transparent structures to
forward social goals. Well beyond voting, it refers to cooperation and participation in all
institutions that direct society and shape people’s lives. These institutions include the
family, schools, and businesses, as well as greater popular control over and access to
basic decision-making processes that determine what gets produced and distributed and
for whom. Democracy’s roots in this regard derive from principles of inclusion rather
than exclusion. Greater democracy means subjecting more issues and investment
decisions to public decision-making. Achieving democracy is about ensuring that claims
for freedom and equality receive adequate expression.
Comment
Eliminating health inequity based on principles of social justice means focusing on the
underlying injustices that originate with racism, class, and gender discrimination
embedded in society’s structure and institutions. Such an approach provides a framework
and adds a value or moral judgment to the empirical findings of social inequality that
cause health inequity. Thus, it is not the mere fact of unequal health outcomes but their
basis within unjust social, political, and economic institutions that is of concern. Such a
perspective will emphasize necessary social change that tackles the accumulation of
conditions, based on a long legacy of injustices leading to poor health outcomes, in
addition to exploring remedies for diseases.
Stated another way, “the pursuit of health equity [is viewed as] embedded in and
interlinked with the pursuit of social justice….[D]ifferences in health outcomes [are]
inequitable if they are the result of unjust social arrangements. The emphasis thus lies not
on the pattern of distribution of health outcomes but on the broader social processes
underlying health inequalities.”
Source: Fabienne Peter, “Health Equity and Social Justice,” in Sudhir Anand, et al.
Public Health, Ethics, and Equity (Oxford University Press, 2004):94-95.
“Social justice is the foundation of public health. This powerful proposition—still
contested—first emerged around 150 years ago during the formative years of public
health as both a modern movement and a profession. It is an assertion that reminds us that
public health is indeed a public matter, that societal patterns of disease and death, of
health and well-being, of bodily integrity and disintegration, intimately reflect the
workings of the body politic for good and for ill. It is a statement that asks us, pointedly,
to remember that worldwide dramatic declines—and continued inequalities—in mortality
and morbidity signal as much the victories and defeats of social movements to create a
just, fair, caring, and inclusive world as they do the achievement s and unresolved
challenges of scientific research and technology.”
Source: Nancy Krieger, “Comment, A Vision of Social Justice as the Foundation of
Public Health: Commemorating 150 Years of the Spirit of 1848,” 88(11) American
Journal of Public Health (November, 1998): 1603.
“Social inequalities (or inequities) in health refer to health disparities, within and between
countries, that are judged to be unfair, unjust, avoidable, and unnecessary (meaning: are
neither inevitable nor un-remediable) and that systemically burden populations rendered
vulnerable by underlying social structures and political, economic, and legal institutions.
As such, social inequalities (or inequities) in health are not synonymous with ‘health
inequalities,’ as this latter term can be interpreted to refer to any difference and not
specifically to unjust disparities. For example, recently proposed measures of ‘health
inequalities’ deliberately quantify distributions of health in populations without reference
to either social groups or social inequalities in health….Promoting equity and
diminishing inequity requires not only a ‘process of continual equalization’ but also a
‘process of abolishing or diminishing privileges.’ Thus pursuing social equity in health
entails reducing excess burden of ill health among groups most harmed by social
inequities in health, thereby minimizing social inequalities in health and improving
average levels overall.”
Source: Nancy Krieger, “A Glossary for Social Epidemiology,” Journal of Epidemiology
and Community Health, 55 (2001): 693.