center on social disparities in health university of california, san francisco the concept &...

CENTER ON SOCIAL DISPARITIES IN HEALTHUniversity of California, San Francisco

The concept & measurement of health inequalities and health equity: not merely a technical matter

International Society for Equity in HealthCartagena, ColombiaSeptember 26, 2011

Paula Braveman, MD, MPHUniversity of California, San FranciscoProfessor of Family & Community MedicineDirector, Center on Social Disparities in Health


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


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


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?


What if the causes are not known?

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?

In the USA, compared with European-American (“White”) newborns, African-American (“Black”) newborns are 2 to 3 times as likely:


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?


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


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


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


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


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


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


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).


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


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


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

center on social disparities in health university of california, san francisco the concept &...

Documents

health slide

health equity

health problems

health cartagena

minority health

health disparities nimhd

health differences unfair

avoidable health difference