Understanding Health Inequalities and Justice

New Conversations across the Disciplines

Mara Buchbinder,Michele Rivkin-Fish,Rebecca L. Walker

• Publisher: The University of North Carolina Press
• Year: 2016
• ISBN:
  9781469630366
• Topic: Medicine
• Subtopic: Health Policy

The need for informed analyses of health policy is now greater than ever. The twelve essays in this volume show that public debates routinely bypass complex ethical, sociocultural, historical, and political questions about how we should address ideals of justice and equality in health care. Integrating perspectives from the humanities, social sciences, medicine, and public health, this volume illuminates the relationships between justice and health inequalities to enrich debates. Understanding Health Inequalities and Justice explores three questions: How do scholars approach relations between health inequalities and ideals of justice? When do justice considerations inform solutions to health inequalities, and how do specific health inequalities affect perceptions of injustice? And how can diverse scholarly approaches contribute to better health policy? From addressing patient agency in an inequitable health care environment to examining how scholars of social justice and health care amass evidence, this volume promotes a richer understanding of health and justice and how to achieve both. The contributors are Judith C. Barker, Paula Braveman, Paul Brodwin, Jami Suki Chang, Debra DeBruin, Leslie A. Dubbin, Sarah Horton, Carla C. Keirns, J. Paul Kelleher, Nicholas B. King, Eva Feder Kittay, Joan Liaschenko, Anne Drapkin Lyerly, Mary Faith Marshall, Carolyn Moxley Rouse, Jennifer Prah Ruger, and Janet K. Shim.

Part I: Interrogating Normative Perspectives on Health Inequality and Justice

1: Health Difference, Disparity, Inequality, or Inequity—What Difference Does It Make What We Call It?

An Approach to Conceptualizing and Measuring Health Inequalities and Health Equity

Paula Braveman

ABSTRACT

Over the past two and a half decades, distinct approaches have been taken to defining and measuring health inequalities or disparities and health equity. Some efforts have focused on technical issues in measurement, often without addressing the implications for the concepts themselves and how that might influence action. Others have focused on the concepts, often without addressing the implications for measurement. This chapter contrasts approaches that have been proposed, examining their conceptual bases and implications for measurement and policy. It argues for an approach to defining health inequalities and health equity that centers on notions of justice and has its basis in ethical and human rights principles as well as empirical evidence. According to this approach, health inequality or disparity is used to refer to a subset of health differences that are closely linked with—but not necessarily proven to be caused by—social disadvantage. The term “inequity,” which means injustice, could also be used, but arguments are presented for using it somewhat more sparingly, for those inequalities or disparities in health or its determinants that we know are caused by social disadvantage.

BACKGROUND AND OVERVIEW

Over the past two and a half decades, distinct approaches have been taken to defining and measuring health inequalities or disparities and health equity. Some efforts have focused on technical issues in measurement, at times without addressing the implications for the concepts themselves and how that might influence action. Others have focused on the concepts, sometimes without adequately addressing the implications for measurement. This chapter contrasts a few different approaches, examining their conceptual bases and the implications for measurement and policy. It argues for an approach to defining health inequalities and health equity that centers explicitly on notions of justice and has its basis in ethical and human rights principles as well as empirical evidence.

According to this human-rights-based approach, health inequalities or disparities are potentially avoidable differences in health that adversely affect socially disadvantaged groups, and, more specifically, groups that have experienced discrimination or social exclusion.¹ The concept of “health inequalities” refers to a subset of health differences that are closely linked to, but not necessarily proven to be caused by, social disadvantage. The differences may have been caused by social disadvantage, but proof of their causation is not required to call them inequalities/disparities. These health differences are unfair because they put an already socially disadvantaged group at further disadvantage with respect to their health, and health is needed to escape social disadvantage. These differences can be measured. The term “inequity,” which means injustice, could also be used for such differences, but arguments are presented here for using that term somewhat more sparingly, to refer to those inequalities or disparities in health or its determinants that we know are caused by social disadvantage. The sharpest contrast with the rights-based approach is with an approach that may be referred to as the “ungrouped” or “univariate” approach, which compares individuals based only on their health, rather than examining how health is distributed across different social groups. Another approach is to compare groups but not restrict the comparisons to those reflecting social advantage. This chapter discusses these approaches, their conceptual foundations, and their implications.

Unlike the other two approaches, the human-rights-based approach acknowledges that values inevitably play an important role in science, shaping the questions we ask and sometimes the methods we use. For example, King comments in this volume that “normative judgments about inequity are often embedded in measures of inequality” (218). And in her chapter on global health inequalities and justice, Ruger notes, “An essential first step in redressing wrongs is exposing the wrongs and making explicit the values on which proposed action is based” (70). Wrongs can be hidden in data that are not broken down by meaningful markers of social advantage and disadvantage. I believe that our values are always operating, regardless of whether we are aware of them, and should be made explicit. Scientists must constantly strive to eliminate distortion of the truth arising from any source, including consciously or unconsciously held values.

THE NEED FOR A CONCEPTUALLY SOUND DEFINITION OF HEALTH INEQUALITIES AND EQUITY

Health disparity or inequality is hardly a household term anywhere, but over the course of the last fifteen to twenty-five years it has become increasingly familiar in public health and medical circles in the United States and elsewhere. It is, however, rarely defined. In the United States, without further explanation, health disparity is generally assumed to refer to racial or ethnic disparities in health. The term “health disparities” first came into wide use with initiatives around the year 2000, including the establishment of the Office of Minority Health within the U.S. Department of Health and Human Services. The National Institutes of Health defines health disparities as differences in health among “specific populations,” without identifying the criteria that would help one decide which groups are relevant. If interpreted literally, this definition would include all differences in health among any groups of people, such as relatively worse health among the elderly than among young adults, or a higher incidence of arm or leg fractures among skiers than among nonskiers. The label is also used at times to refer to socioeconomic and other forms of disparities (e.g., gender, sexual orientation, gender identity, or disability) as well. Outside the United States, the term “health inequalities,” which first came into widespread public health usage in the United Kingdom and Western Europe in the 1990s, has prevailed. There, “health inequalities” has primarily been used to refer to differences in health among different socioeconomic groups, although it also has been used at times to refer to health differences by gender, ethnic group, nativity, and other social characteristics. In this chapter, “inequality” and “disparity,” whose dictionary definitions are the same, are used interchangeably, while the related terms “equity” and, by implication, “inequity” are seen as distinct.

The term “health inequity” has also been used both within and outside the United States. A succinct and eloquent definition of health inequity was coined by Margaret Whitehead in the United Kingdom almost twenty-five years ago. She defined health inequities as differences in health that are avoidable, unnecessary, unfair, and unjust (Whitehead 1992). That definition has provided inspiration and guidance globally. However, in some situations, notably those where a strong sense of social solidarity is lacking, more specificity may be needed. Notions of what is avoidable and unnecessary vary greatly. For example, many believe that “the poor will always be with us” and that the poor will tend to have worse health because they often have poor health-related behaviors for which they are to blame. Similarly, notions of what is fair and just can be strikingly different. For example, in the United States, attitudes toward progressivity in taxation vary dramatically, and in some parts of the world it is considered fair that women have few legal rights because of deeply held beliefs about women’s proper roles in the society. Agencies charged with addressing health disparities may sometimes face pressures to allocate their limited resources to address health differences affecting groups that are not socially disadvantaged, such as a health difference between two affluent communities. Given the lack of clarity regarding the concepts of health inequalities/disparities and equity, over the past two decades, a series of technical and sometimes political challenges have emerged, threatening to derail efforts to achieve greater social justice in the health domain. I have attempted to produce a definition that can withstand many of the actual and potential challenges that could jeopardize efforts toward greater health equity. Key criteria for a definition are that it be both conceptually and technically sound and that it can be operationalized for the purpose of measurement; without measurement there is no accountability.

DEFINING HEALTH INEQUALITIES AND EQUITY BASED ON HUMAN RIGHTS AND ETHICS

Based on principles from the fields of ethics and human rights (discussed below), health inequalities or disparities are defined as potentially avoidable differences in health that adversely affect socially disadvantaged groups, particularly groups that have experienced discrimination or social exclusion. The differences must be systematic, not exceptions (Starfield 2001). Avoidability does not have to be proven, but it must be at least theoretically plausible, that is, biologically plausible based on the best available scientific knowledge. It is not essential to know that the inequalities were caused by social injustice. To determine whether a potentially avoidable difference is a health inequality or not, it is only necessary to establish that the difference involves worse health (or greater health risk) among groups that are socially disadvantaged. (Differences in the factors that shape health and that adversely affect disadvantaged groups also may be thought of as health inequalities or more precisely as inequalities in opportunities to be healthy.)

Equity and equality are not the same. Equity is an ethical value. Merriam-Webster Online (2014) defines equity as “fairness or justice in the way people are treated.” Health equity means fairness or justice in how people are treated, insofar as it affects their health. It means equal opportunities to be healthy. While equal rights and equal treatment under the law reflect values, equality, like parity, may refer simply to numerical equivalence. Equal treatment for all groups may be unjust when some groups, such as those who are socially disadvantaged, need more resources or services to be healthy than those who are better off. In some societies that are particularly oppressive to women, for example, women’s life expectancy is equal to that of men. However, in all societies in which women are not extremely disadvantaged by their gender, women generally live longer than men. Several scholars have concluded that this is biologically based (Fukuda-Parr and Shiva Kumar 2003; Holden 1987; Sen 1992; Anand and Sen 1996; Waldron 1983) rather than reflecting inequitable treatment of males. Thus, equal life expectancy for men and women would not be equitable. Similarly, disparity or inequality could potentially refer neutrally just to any difference, without qualification, but both terms generally imply that there is something about the specified difference that does not seem right.

One might ask whether we can just use “inequality” and “disparity” in a value-neutral way, and use “inequity” to refer to differences seen as unfair. On the surface, this has strong appeal. I believe, however, that there is value in retaining the terms “health inequality” or “disparity” in the public health lexicon to refer not only to any differences or variations in health and its determinants but, more specifically, to those differences or variations that raise concerns about justice, even though definitive proof of their causation may not be available. There may be limited acceptance for calling many important health differences “health inequities” when knowledge of their causes is lacking, as is often the case. Examples of health inequity, following this perspective, would include shorter life expectancy among American Indians and African Americans than among European Americans in the United States, higher rates of child mortality in many resource-poor countries than in more affluent nations, and higher rates of lead poisoning among children in poor families than among children in more affluent families. Many would not consider the black-white disparities in birth weight, premature birth rate, and breast cancer mortality health inequities because their causes are unknown. They would, however, qualify as health inequalities/disparities, warranting inclusion in the health equity research agenda.

Not all health differences are health inequalities or disparities. Furthermore, not all health differences that warrant concerted attention are health inequalities; criteria in addition to equity, such as effectiveness and efficiency, need to be considered along with equity. Health inequalities are a particular subset of health differences that are closely linked to social advantage and disadvantage. They adversely affect groups of people who are socially disadvantaged, as reflected by their low levels of wealth, influence, prestige, or acceptance in society. Socially disadvantaged groups include, but are not limited to, people who have low incomes, low educational levels, little wealth, or low-status jobs; members of disadvantaged racial or ethnic groups; members of sexual minority groups (defined by sexual orientation or gender identity); disabled persons; in many contexts, women; and other groups that have historically experienced discrimination, exclusion, or marginalization (Braveman, Kumanyika, et al. 2011; USDHHS and ODPHP 2011). Whether a group has historically experienced discrimination or been excluded or marginalized can be documented empirically.

While distinct, health equity and health inequalities are intrinsically intertwined. Equity is the value, the principle that underlies a commitment to reduce and ultimately eliminate health inequalities. Inequalities/disparities in health and in the determinants of health, including social determinants as well as medical care, are the metric used to assess progress toward greater equity in health. Health equity means social justice in health. Pursuing health equity means striving for the highest possible standard of health for all people while giving special attention to the needs of those at greatest risk of poor health on the basis of their social conditions. A reduction in health inequalities (in absolute and relative terms) is evidence that we are moving toward greater health equity. The reference group for equity comparisons should be the most socially advantaged group in a society; their health indicates what should be possible for everyone. Moving toward greater equity is achieved by selectively improving the health of those who are socially disadvantaged, not by a decline in the health of those in advantaged groups.

THE EMPIRIC, ETHICAL, AND HUMAN RIGHTS BASIS FOR DEFINING HEALTH INEQUALITIES BASED ON SOCIAL ADVANTAGE AND DISADVANTAGE

What is the basis for singling out a particular category of health differences, namely those linked with social disadvantage, for special attention? The characteristics that define the relevant groups—wealth, education, occupational rank, race or ethnic group, gender, sexual orientation or gender identity, disability—are not chosen on a whim. They are chosen based on extensive evidence collected over centuries that social disadvantage is powerfully linked with ill health, and on widely held values articulated in the fields of ethics and human rights.

Empirical Evidence

A massive body of evidence strongly links social disadvantage with avoidable illness, disability, suffering, and premature death. Many, but not all, who have studied this evidence believe the links are causal (Braveman 2010; Adler and Stewart 2010; WHOCSDH 2008; Krieger 2001; Virchow 2006; Rosen 1993; Winslow 1948). King (chapter 8, this volume) claims that the evidence that social advantage affects health consists only of associations, not causal links. I disagree. The evidence base repeatedly links various forms of social advantage/disadvantage with diverse health outcomes in diverse settings and populations, and it includes far more than just observed associations. The body of knowledge on the social determinants of health comes from research with a range of designs, including longitudinal studies that establish the temporal sequence of predictors and outcomes and quasi-experimental studies using varied techniques to address potential bias. The evidence base includes some experimental evidence, although the latter is more limited largely because it is often unethical or unfeasible to randomly assign which people will receive an intervention whose health effects (which the study aims to examine) may be uncertain but whose other benefits (e.g., additional schooling or ...