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Published Ahead of Print on May 6, 2011, as 10.2105/AJPH.2010.300062       The latest version is at http://ajph.aphapublic...
ANALYTIC ESSAY FORUM  process. The Nobel Laureate  economist Amartya Sen31                  Health Disparities and Health ...
ANALYTIC ESSAY FORUM  equalizing the rights of vulner-          those who were worse off to           demonstrated. Differ...
ANALYTIC ESSAY FORUMPlausibly Avoidable                       and efficiently to reduce important     Disadvantaged Groups ...
ANALYTIC ESSAY FORUMHealth Disparities as the                Health inequity, however, is a           Limitations         ...
ANALYTIC ESSAY FORUMample evidence has documented                 Francisco, 3333 California St., Suite 365,       2020, N...
ANALYTIC ESSAY FORUM33. Jones CP. Levels of racism: a theo-       Assuring Healthy Outcomes, Board on             59. Henr...
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Health Disparities and Health Equity: The Issue Is Justice


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Health Disparities and Health Equity: The Issue Is Justice

  1. 1. Published Ahead of Print on May 6, 2011, as 10.2105/AJPH.2010.300062 The latest version is at ANALYTIC ESSAY FORUMHealth Disparities and Health Equity: The Issue Is Justice Eliminating health dis- Paula A. Braveman, MD, MPH, Shiriki Kumanyika, PhD, MPH, Jonathan Fielding, MD, MPH, MA, MBA, parities is a Healthy Peo- Thomas LaVeist, PhD, Luisa N. Borrell, DDS, PhD, Ron Manderscheid, PhD, ple goal. Given the diverse and Adewale Troutman, MD, MPH, MA and sometimes broad defi- nitions of health disparities commonly used, a sub- ONE OF 2 OVERARCHING cultural, and technical perspec- wording. Clarifying these concepts committee convened by the goals of Healthy People 20101 was tives may generate different defi- will enable medical and public Secretary’s Advisory Com- ‘‘to eliminate health disparities nitions of health disparities or in- health practitioners and leaders to mittee for Healthy People among different segments of the equalities (the most comparable be more effective in reducing dis- 2020 proposed an opera- population.’’ A similar goal to term outside the United States).9---21 parities in medical care and in tional definition for use in ‘‘achieve health equity and elimi- For example, in the United King- advocating for social policies (e.g., developing objectives and nate health disparities’’ was pro- dom, Whitehead defined health in child care, education, housing, targets, determining re- posed by the Health and Human inequalities as differences that are labor, and urban planning) that source allocation priorities, and assessing progress. Services Secretary’s Advisory unnecessary, avoidable, and un- can have major impacts on popu- Based on that subcom- Committee (SAC) for Healthy Peo- fair.21 This definition is widely lation health.27 mittee’s work, we propose ple 2020.2 Healthy People 2010 used internationally, where that health disparities are noted that health disparities ‘‘in- ‘‘health inequalities’’ are assumed UNDERLYING VALUES AND systematic, plausibly avoid- clude differences that occur by to be socioeconomic differences PRINCIPLES able health differences ad- gender, race or ethnicity, educa- unless otherwise specified; in the versely affecting socially tion or income, disability, living in United States, however, ‘‘health The concepts of health dispar- disadvantaged groups; they rural localities, or sexual orienta- disparities’’ more often refer to ities and health equity are rooted may reflect social disad- tion.’’1 However, the rationale for racial or ethnic differences. in deeply held American social vantage, but causality need identifying disparities in relation Effective public policies require values and pragmatic consider- not be established. This def- to these particular population clear and contextually relevant ations, as well as in internationally inition, grounded in ethical and human rights princi- groups was not articulated. The operational definitions to support recognized ethical and human ples, focuses on the subset National Institutes of Health de- the development of objectives and rights principles.9 Drawing on of health differences re- fined health disparities as ‘‘differ- specific targets, determine priori- ethical and human rights concepts, flecting social injustice, ences in the incidence, prevalence, ties for use of limited resources, key principles underlying the distinguishing health dis- mortality, and burden of diseases and assess progress. The need for concepts of health disparities and parities from other health and other adverse health condi- clear definitions is particularly health equity include the following: differences also warranting tions that exist among specific compelling given the lack of prog- concerted attention, and population groups in the United ress toward reducing racial/ethnic All people should be valued from health differences in States’’3,4; several other federal and socioeconomic disparities in equally. This concept was artic- general. agencies have similarly broad medical care22 and health.23---25 ulated by Jones et al.28 as foun- We explain the definition, definitions.5 The lack of explicit Recognizing the practical implica- dational to the concept of eq- its underlying concepts, the challenges it addresses, and criteria for identifying disparities tions of lack of clarity on this uity. Equal worth of all human the rationale for applying it to in Healthy People 20101 and the critical issue, the SAC convened beings is at the core of the United States public health relatively nonspecific definitions a subcommittee to define ‘‘health human rights principle that all policy. (Am J Public Health. of disparities used by federal disparity’’ and ‘‘health equity’’ for human beings equally possess Published online ahead of agencies3,4 leave considerable use in Healthy People 2020.2 The certain rights.29,30 print May 5, 2011: e1–e7. room for ambiguity as to what subcommittee members, including Health has a particular value for doi:10.2105/AJPH.2010. other groups might also be rele- both SAC members and external individuals because it is essential 300062) vant. experts, wrote this paper to elab- to an individual’s well-being Furthermore, there has been orate on the definitions and ex- and ability to participate fully in controversy as to whether defini- plain their rationale.2,26 These defi- the workforce and a democratic tions of health disparities should nitions (see the box on the next society. Ill health means potential imply injustice or simply reflect page) and the rationale presented suffering, disability, and/or loss differences in health outcomes are substantively consistent with of life, threatens one’s ability to that might apply to any United those adopted by the SAC and re- earn a living, and is an obstacle States population segment.6---8 Dif- cently published in Healthy People to fully expressing one’s views ferent ethical, philosophical, legal, 2020,2 but reflect some changes in and engaging in the politicalPublished online ahead of print May 5, 2011 | American Journal of Public Health Braveman et al. | Peer Reviewed | Analytic Essay Forum | e1 Copyright 2011 by the American Public Health Association
  2. 2. ANALYTIC ESSAY FORUM process. The Nobel Laureate economist Amartya Sen31 Health Disparities and Health Equity viewed health as a fundamental Health disparities are health differences that adversely affect socially disadvantaged groups. capability required to function Health disparities are systematic, plausibly avoidable health differences according to race/ethnicity, in society; similarly, ill health skin color, religion, or nationality; socioeconomic resources or position (reflected by, e.g., income, can be a barrier to fully re- wealth, education, or occupation); gender, sexual orientation, gender identity; age, geography, disability, illness, political or other affiliation; or other characteristics associated with discrimination alizing one’s human rights. or marginalization. These categories reflect social advantage or disadvantage when they determine Because ill health can be an an individual’s or group’s position in a social hierarchy (see the box on the next page). obstacle to overcoming disad- Health disparities do not refer generically to all health differences, or even to all health differences vantages, health disparities, warranting focused attention. They are a specific subset of health differences of particular relevance which further disadvantage so- to social justice because they may arise from intentional or unintentional discrimination or cially disadvantaged groups, marginalization and, in any case, are likely to reinforce social disadvantage and vulnerability. seem particularly unfair. Disparities in health and its determinants are the metric for assessing health equity, the principle Nondiscrimination and equality. underlying a commitment to reducing disparities in health and its determinants; health equity is Every person should be able to social justice in health. achieve his/her optimal health status, without distinction based on race or ethnic group, skin obligation to maximize the well- governments to respect, protect, housing, environmental protec- color, religion, language, or na- being of those worst off. An fulfill, and promote all human tion, and other factors that are tionality; socioeconomic re- aversion to discrimination is rights of all persons, including also crucial to health and well- sources or position; gender, also firmly rooted in United the ‘‘right to the highest attain- being.38 sexual orientation, or gender States policies, as exemplified by able standard of health’’ and the Health differences adversely af- identity; age; physical, mental, the Civil Rights Act of 1964 right to a standard of living fecting socially disadvantaged or emotional disability or ill- prohibiting discrimination on adequate for health and well- groups are particularly unac- ness; geography; political or the basis of race, color, or na- being. Governments must dem- ceptable because ill health can be other affiliation; or other char- tional origin; the 1954 Brown onstrate good faith in progres- an obstacle to overcoming social acteristics that have been linked vs. Board of Education decision sively removing obstacles to re- disadvantage. This consideration historically to discrimination or desegregating schools; the Hill alizing these rights.29 The United resonates with common sense marginalization (exclusion from Burton Act of 1946 prohibiting States signed but did not ratify notions of fairness, as well as social, economic, or political hospitals receiving federal funds the International Covenant on with ethical concepts of justice, opportunities). The groups rep- from discriminating on the basis Economic, Social, and Cultural notably, the concept that need resented by these characteristics of race, color, or creed; and the Rights, which articulated the should be a key determinant of substantively agree with those Americans with Disabilities Acts right to health. Signing a treaty, resource allocation for health, specified by the United Nations of 1990 and 2008 prohibiting however, is considered an en- and Rawls’ notion of the obli- Committee on Economic, Social discrimination on the basis of dorsement of its principles and gation to maximize the well- and Cultural Rights as vulnera- physical or mental disability. reflects acceptance of a good being of those worst off.39 ble groups whose rights are at Health is also of special impor- faith commitment to honor its Sen noted as a ‘‘particularly se- particular risk of being unreal- tance for society because a na- contents. The ‘‘right to health’’ rious . . . injustice . . . the lack ized, due to historic discrimina- tion’s prosperity depends on the (i.e., ‘‘the right of everyone to the of opportunity that some may tion.32 This directly reflects the entire population’s health. enjoyment of the highest attain- have to achieve good health human rights principles of Healthy workers are more pro- able standard of physical and because of inadequate social nondiscrimination and equality; ductive and generate lower an- mental health’’37) is ‘‘not to be arrangements. . . .’’40 Sen argued nondiscrimination includes nual medical care costs.34---36 understood as a right to be heal- that health is a prerequisite for not only intentional but also A healthier population has thy,’’ because too many factors the capability to function nor- unintentional or de facto more workers available for the beyond states’ control influence mally in society.31 It is therefore discrimination, meaning dis- workforce. Health can facilitate health. Rather, it is ‘‘the right to particularly unjust that those criminatory treatment embed- political participation, which a system of health protection who are socially disadvantaged ded in structures and institu- is essential for democracy. which provides equality of op- should also experience addi- tions, regardless of whether Rights to health and to a standard portunity to enjoy the highest tional obstacles to opportunity there is conscious intent to dis- of living adequate for health. In- attainable level of health.’’ It in- based on having worse health. criminate.32,33 The late philos- ternational human rights agree- cludes the right to equal access to Ratifying human rights agree- opher John Rawls19 advanced ments, to which virtually all cost-effective medical care as ments obliges governments to the concept of a society’s ethical countries are signatories, obligate well as to child care, education, direct special effort towarde2 | Analytic Essay Forum | Peer Reviewed | Braveman et al. American Journal of Public Health | Published online ahead of print May 5, 2011
  3. 3. ANALYTIC ESSAY FORUM equalizing the rights of vulner- those who were worse off to demonstrated. Differences among difficult to overcome social disad- able groups facing more obsta- start, within an overall strategy groups in their levels of social vantage. This reinforcement or cles to realizing their rights. A to improve everyone’s health. advantage or disadvantage, which compounding of social disadvan- nonexhaustive list of vulnerable Closing health gaps by worsen- can be thought of as where tage is what makes health dispar- groups is specified in human ing advantaged groups’ health is groups rank in social hierarchies, ities relevant to social justice even rights documents on non- not a way to achieve equity. are indicated by measures when knowledge of their causa- discrimination and equal- Reductions in health disparities reflecting the extent of wealth, tion is lacking. It is important to ity.32,37,41,42 (by improving the health of the political or economic influence, define health disparities without The resources needed to be socially disadvantaged) are the prestige, respect, or social accep- requiring proof of causality, be- healthy (i.e., the determinants of metric by which progress to- tance of different population cause there are important health health, including living and ward health equity is measured. groups. disparities for which the causes working conditions necessary for have not been established, but health, as well as medical care) HEALTH DISPARITIES: Systematic But Not which deserve high priority based should be distributed fairly. To DEFINITION AND Necessarily Causal Links With on social justice concerns. For do so requires considering need RATIONALE Social Disadvantage example, the large Black---White (along with capacity to benefit16 As noted by Starfield,45 health disparity in low birth weight and efficiency17) rather than We briefly define health dis- disparities are systematic, that is, and premature birth strongly pre- ability to pay or influence in parities and health equity (see the not isolated or exceptional find- dicts disparities in infant mortality society.17 This principle, along box on the previous page), elabo- ings. Health disparities are sys- and child development, and with principles cited previously, rating further and explaining in tematically linked with social dis- likely in adult chronic disease.46 reflects the ethical notion of this section. We also discuss social advantage, and may reflect social Although the causes of racial distributive justice (a just distri- disadvantage, a key concept for disadvantage, although a causal disparity in birth outcomes are bution of resources needed for understanding disparities and eq- link does not need to be demon- not established,46 credible health) and the human rights uity (see the box on this page). strated. Whether or not a causal scientific sources have identified principles of nondiscrimination Health disparities are systematic, link exists, health disparities ad- biological mechanisms that plau- and equality, as well as the plausibly avoidable health differ- versely affect groups who are al- sibly contribute to the dispar- right to a standard of living ade- ences adversely affecting socially ready disadvantaged socially, put- ities,46---50 which reflect phenom- quate for health. Investments disadvantaged groups. They may ting them at further disadvantage ena shaped by social contexts and in medical care intended to reflect social disadvantage, al- with respect to their health, thus are, at least theoretically, reduce disparities must be though a causal link need not be thereby making it potentially more avoidable. weighed against other poten- tially more effective invest- ments that address disparities in other health determinants.38 Social Disadvantage Health equity is the value under- Health disparities and health equity cannot be defined without defining social disadvantage. lying a commitment to reduce and Social disadvantage refers to the unfavorable social, economic, or political conditions that some ultimately eliminate health dis- groups of people systematically experience based on their relative position in social hierarchies. parities. It is explicitly men- It means restricted ability to participate fully in society and enjoy the benefits of progress. Social tioned in the Healthy People disadvantage is reflected, for example, by low levels of wealth, income, education, or occupational 2020 2 objectives. Health eq- rank, or by less representation at high levels of political office. Criteria for social disadvantage can uity means social justice with be absolute (e.g., the federal poverty threshold in the United States is based on an estimate of the respect to health and reflects the income needed to obtain a defined set of basic necessities for a family of a given size)43 or relative ethical and human rights con- (e.g., poverty levels in a number of European countries are defined in relation to the median cerns articulated previously. income, e.g., less than 50% of the median income).44 Health equity means striving to Not all members of a disadvantaged group will necessarily be (uniformly) disadvantaged, and not all equalize opportunities to be socially disadvantaged groups will necessarily manifest measurable adverse health consequences. The extent (whether in a single or multiple domains), depth (severity), and duration (e.g., across healthy. In accord with the multiple generations) of disadvantage matter. Social disadvantage is different from unavoidable other ethical principles of be- physical disadvantage due to, for example, an unavoidable physical disability. However, when neficence (doing good) and disabled persons are put at an unnecessary disadvantage in society due to lack of feasible nonmalfeasance (doing no supports (e.g., accessible public buildings and transportation) or to discrimination against them in harm), equity requires con- hiring for work that they could perform, this would constitute social disadvantage, certed effort to achieve more reflecting discriminatory treatment, whether intentional or unintentional. rapid improvements amongPublished online ahead of print May 5, 2011 | American Journal of Public Health Braveman et al. | Peer Reviewed | Analytic Essay Forum | e3
  4. 4. ANALYTIC ESSAY FORUMPlausibly Avoidable and efficiently to reduce important Disadvantaged Groups Are Not issue is whether the group has beenDifferences in Health Given disparities. Necessarily Uniformly on the whole more disadvantagedSufficient Political Will Disadvantaged than Whites. Ample evidence has It must be plausible, but not Worse Health Among Socially Internationally recognized hu- documented a longstanding patternnecessarily proven, that policies Disadvantaged Groups man rights documents provide of less wealth,60,61 lower incomes,could reduce the disparities, in- Socially disadvantaged groups guidance on which groups are lower educational attainment, andcluding not only policies affecting are defined a priori, according to disadvantaged. Although health under-representation in positionsmedical care but also social poli- criteria consistent with human disparities are systematic, a so- of high occupational rank56 andcies addressing important non- rights principles regarding non- cially disadvantaged group will financial and political power62medical determinants of health discrimination and equality. not necessarily fare worse on all among Blacks as a group com-and health disparities, such as a Health disparities and equity health indicators, and might fare pared with Whites. Despite an end should be central considerations better on some. For example, non- to legal racial segregation decadesdecent standard of living; a level of for public policy relevant to Hispanic European American or ago, racial residential segregationschooling permitting full social health, but they are not the only White (hereafter ‘‘White’’) women persists and with it, de facto edu-participation, including participa- considerations. Other legitimate over age 40 have higher incidence cational segregation, condemningtion in the workforce and political considerations include the mag- of breast cancer than non-His- many Black children to pooractivities; health-promoting living nitude of impact and proportion quality schools. This reduces theirand working conditions, includ- panic African American or Black of the population affected, as chances of obtaining good jobsing both social and physical envi- (hereafter ‘‘Black’’) women,54 and well as efficiency in the use of with adequate income as adults,ronments; and respect and social babies born to Hispanic immigrant resources. If a more socially perpetuating social disadvantageacceptance.23,51 This criterion women often have more favorable advantaged group happens to across generations.63,64addresses the issue of avoidability, birth weights than those born to fare worse on a particular health Similarly, although manywhich is central to Whitehead’s non-Hispanic Whites.55 Neither of indicator, this may be a very im- United States women are affluent these differences– –although bothdefinition of health inequalities; it portant issue that public health and some now hold high profes- deserve public health attention– –strives for more specificity about or other sectors should energeti- sional and political offices, as would be a health disparity by theavoidability and to clarify the bur- cally address; but it is not part of a group, they are more likely proposed definition. Regardlessden of proof regarding causality.21 a ‘‘health disparities’’ agenda, than men to be poor,65 to earn of this type of exception in relation Avoidability can be highly sub- which focuses on improving the less at a given educational level,66 to a health outcome, Whites asjective. For example, one person health of socially disadvantaged and to be underrepresented inmay believe that ill health caused groups. a group are more socially advan- high political office.67 Humanby poverty is avoidable; another, taged than Blacks and Hispanics, rights documents on nondiscrim-however, may believe that both The Need to Reduce as data on income, wealth, educa- ination explicitly name women aspoverty and ill health among the Disparities in the tion, occupations, and political a vulnerable group warrantingpoor are inevitable; hence, these Determinants of Health office have documented.56---58 special protection from discrimi-disparities are unavoidable. Ac- Health determinants include Furthermore, on most health indi- nation. Patterns suggesting clini-cording to the proposed definition, not only medical care but also the cators, including breast cancer mor- cally unjustified underreceipt ofthe criterion is whether the given quality of the social and physical tality, White women are healthier certain cardiac treatments bycondition is theoretically avoidable, conditions in which people live, than Black women.59 Similarly, women compared with men68based on current knowledge of work, learn, and play.23,51,52 higher rates of a preventable would reflect a gender disparityplausible causal pathways and bi- Evidence of disparities in health illness in 1 of 2 affluent geographic in a determinant of healthological mechanisms, and assuming determinants is thus relevant to regions would warrant public (medical care, in this instance).the existence of sufficient political assessing disparities in health. health action, but not as a health Shorter life expectancy amongwill. The more solid the knowl- Society will generally be more disparities concern. men in general, if likely avoid-edge, the more reasonable and motivated to address health dif- The fact that not all members able, would clearly be an issue ofpolitically viable it will be to invest ferences that appear to result of a disadvantaged group (e.g., public health importance basedresources in interventions; feasi- from modifiable circumstances Blacks) appear to be severely dis- on the magnitude of potentialbility, costs, and potentially harm- over which individuals may have advantaged (e.g., we have a Black population impact. However,ful unintended consequences little control21,53; for example, United States President, and men as a group have moremust be considered. Without firm the quality of local schools, ex- some Blacks are highly educated, wealth, influence, and prestige, soknowledge to guide specific inter- posure to pollution or crime, in high professional positions, this difference would not beventions, pursuing health equity or absence of stores selling nu- and/or wealthy) does not contra- a social injustice and, therefore,would require supporting research tritious food in one’s neighbor- dict considering that group as not a health disparity or equityon how to intervene effectively hood. generally disadvantaged. The issue.e4 | Analytic Essay Forum | Peer Reviewed | Braveman et al. American Journal of Public Health | Published online ahead of print May 5, 2011
  5. 5. ANALYTIC ESSAY FORUMHealth Disparities as the Health inequity, however, is a Limitations advantage. The causes need not beMetric to Assess Progress forceful term tending to imply These definitions do not pro- known definitively, if it is biologi-Toward Health Equity a strong judgment about causality, vide numerical cutoffs for deter- cally plausible that the difference The stated criteria permit the which may be difficult to support in mining disadvantage. Nor do they could be reduced by policies.assessment of measurable prog- many cases that nevertheless de- remove completely the need to These definitions also ground theress toward greater health equity. serve attention as health disparities exercise judgment based on values concepts of health disparities andSystematic associations with social (i.e., health differences adversely that are likely to vary across in- health equity in internationallydisadvantage can be identified by affecting socially disadvantaged dividuals and societies. It is recognized principles from theobserving a repeated pattern of groups) regardless of their causa- difficult to imagine reasonable fields of ethics and human rights,correlations between measures of tion. As with health equity, mea- definitions of these concepts, giving them universality and du-social disadvantage and a health suring health inequity relies on however, that would provide rigid rability. Although human rightsoutcome. Social advantage and health disparities as the metric. cutoffs, would completely pre- are often honored more in thedisadvantage can be measured by clude the exercise of judgment, breach than in the observance,comparing populations on factors Health Disparity: Not Just and would leave no room for they are a powerful resource insuch as levels of wealth, income, a Health Difference contention. The proposed defini- that they represent a global con-educational attainment, or occu- Interpreting the term ‘‘health tions do not clarify whether the sensus on values. This consensuspational rank, for example (see the disparities’’ as any health differ- reference group for making eq- can be an important point of ref-box on page e3). Demonstrating ences among any population erence in national and local de- uity/disparities comparisonsthat a given disparity is plausibly group, as has been done by some bates on policies and practice in should be the most advantaged federal agencies, encompasses the the United States. It would beavoidable and can be reduced by group in one’s country or in the entire domain of epidemiology, naıve to think that achieving con- ¨policies requires being able to de- world; using one’s country as the which is the study of the distribu- sensus on a definition would ob-scribe, at least in general terms, 1 reference point may ignore the tion of diseases and risk factors viate the need for constant vigi-or more potential causal pathways better health achieved by advan- across different populations. We lance to ensure that the agenda forthat are consistent with current taged populations in other parts of have argued that the term health research and action on health dis-scientific knowledge; it does not the world. disparities should be used advis- parities remains on track and truerequire definitively establishing edly, in the spirit of the movement to the essence of the definition;either the causation of the dispar- Challenges Addressed for social justice from which the however, having a clear definitionity or proving the effectiveness of The definitions address major term emerged, to refer to a partic- is crucial.existing interventions to reduce challenges, such as identifying the ular subset of differences in healthit. Guidelines for measuring health social groups to be compared and that meet well-specified criteria The Issue is Justicedisparities are available.9,69---73 specifying the general criteria for of specific relevance to social jus- Could this approach– –putting Increasingly, the term ‘‘health appropriate reference groups for tice. The definitions proposed here health disparities within theinequity’’21,74,75––the opposite of these comparisons.18 These chal- were designed to clarify the con- broader context of ethics and hu-health equity– being used in- –is lenges have arisen when consid- cepts of health disparities and man rights– –jeopardize the limitedstead of ‘‘health disparity’’ to cap- ering health disparity or equity resources allocated to specifically health equity in ways that couldture explicitly the moral dimension stand up to rigorous conceptual issues, with serious implications address racial/ethnic disparities,and differentiate health differences scrutiny as a basis for guiding for resource allocation. These by spreading these resources morethought to reflect injustice from policy and practice and ensuring definitions remove the need to thinly among other disadvantagedhealth differences in general. Ex- accountability, which requires establish the causality and avoid- groups? Would broadening theamples of health differences that clear criteria for measure- ability of each health difference for definition make the concept toowould not be considered health ment.9,69,70 To achieve the de- it to qualify as a health disparity abstract and therefore less com-disparities according to our defi- sired rigor, the full versions of the worthy of special attention. To ad- pelling to the public and policy-nitions (see the box on page e2) proposed definitions are complex dress the difficult issue of causality, makers? We concluded that theinclude: elderly adults generally and technical and will not be suit- our definitions acknowledge that struggle for racial justice, in whichhaving worse health than noneld- able for all audiences; for many a health disparity may or may not efforts to eliminate racial/ethnicerly adults; skiers being at higher audiences, it may be most appro- arise from social disadvantage, but disparities in health are crucial,risk of long-bone fractures than priate to define health disparities it must adversely affect members of has far more to gain than to losenonskiers; and men not having simply as worse health among socially disadvantaged groups; this from making these principles ex-obstetric problems, whereas socially disadvantaged groups can be assessed using epidemiologic plicit. The relevant ethical andwomen do. Both ‘‘health disparity’’ and then elaborate as necessary, data revealing repeated and perva- human rights principles supportand ‘‘health inequity’’ have their drawing on the more comprehen- sive associations between health prioritizing attention to those fac-place in the public health lexicon. sive form of the definitions. indicators and measures of social ing the greatest obstacles, andPublished online ahead of print May 5, 2011 | American Journal of Public Health Braveman et al. | Peer Reviewed | Analytic Essay Forum | e5
  6. 6. ANALYTIC ESSAY FORUMample evidence has documented Francisco, 3333 California St., Suite 365, 2020, November 2010. Available at: 19. Rawls J. A Theory of Justice. Cam- San Francisco, CA 94118 (e-mail: bridge: Belknap/Harvard Universitythe multiple and often crushing Reprints can be about/disparitiesAbout.aspx. Accessed Press; 1971.obstacles faced by members of ordered at by clicking April 8, 2011. 20. Ruger JP. Health and social justice.disadvantaged racial/ethnic the ‘‘Reprints/Eprints’’ link. 3. National Institute of Arthritis and Lancet. 2004;364(9439):1075---1080. This article was accepted November 1,groups in the United States, in Musculoskeletal and Skin Diseases. Strate- 2010. 21. Whitehead M. The concepts andsome cases for centuries. These gic plan for reducing health disparities. Available at: principles of equity and health. Healthprinciples can protect initiatives Promot Int. 1991;6(3):217---228. Contributors About_Us/Mission_and_Purpose/strat_to address racial/ethnic as well as All the authors participated conceptually plan_hd.asp. Accessed September 7, 2010. 22. Voelker R. Decades of work toother disparities in health from in developing the recommendations to 4. National Cancer Institute. Health reduce disparities in health care produce the Secretary’s Advisory Committee disparities defined. Available at: http:// limited success. JAMA. 2008;299(12):a range of potential challenges (SAC) on Healthy People 2020, which 1411---1413.that constitute real threats. were the starting point for this article, and Accessed September 7, 2010. 23. Braveman P, Egerter S. Overcoming Previous official approaches to all authors contributed ideas, reviewed drafts, and made comments that shaped 5. Carter-Pokras O. What is a ‘‘health Obstacles to Health: Report from the Robertdefining health disparities in the disparity’’? Public Health Rep. 2002;117: Wood Johnson Foundation to the Commis- this article in important ways. P. A.United States have avoided being Braveman conceived the initial idea for 426---434. sion to Build a Healthier America. Prince- the article, wrote initial drafts, and wrote ton, NJ: Robert Wood Johnson Founda-explicit about values and princi- 6. Jones CM. The moral problem of most revisions for coauthors’ review, tion; 2008.ples, perhaps for fear of stirring health disparities. Am J Public Health. based on their comments. S. Kumanyika 2010;100(suppl 1):S47---S51. 24. Singh GK, Kogan MD. Wideningpolitical opposition, because of also played a major role in writing the text socioeconomic disparities in US child- and a lead role in responding to external 7. Bloche MG. Health care disparities---genuine differences in values or hood mortality, 1969-2000. Am J Public reviewer comments. J. Fielding, T. LaVeist, science, politics, and race. N Engl J Med.because of the prevailing ethos Health. 2007;97(9):1658---1665. L. N. Borrell, R. Manderscheid, and 2004;350(15):1568---1570.that enjoins researchers to avoid A. Troutman also contributed conceptually 8. Steinbrook R. Disparities in health 25. Singh GK, Siahpush M. Wideningthe realm of values that might and participated in substantive revisions care---from politics to policy. N Engl J Med. socioeconomic inequalities in US life ex- throughout the process. 2004;350(15):1486---1488. pectancy, 1980-2000. Int J Epidemiol.compromise the integrity of their 2006;35(4) Scientists, like all others, 9. Braveman P. Health disparities and Acknowledgments health equity: concepts and measurement. 26. Fielding J, Kumanyika SK. Recom-should be guided by ethical and Annu Rev Public Health. 2006;27:167-- 194. mendations for the concepts and form of We wish to thank Karen Simpkins, MLS,human rights values. The first and Colleen J. Barclay, MPH, for their Healthy People 2020. Am J Prev Med. 10. Daniels N, Kennedy B, Kawach I. 2009;37(3):255---257.decade of the 21st century has assistance with research. Written permis- Justice is good for our health. Boston sion has been obtained from all persons 27. Beyond Health Care. New Directionsended with little if any evidence Review 2000 February/March 25(1): named here. The authors take full re- to a Healthier America. Recommendations 4---19.of progress toward eliminating sponsibility for the contents of this paper from the Robert Wood Johnson Foundationhealth disparities by race or so- as individuals. This article is not an official 11. Wagstaff A, van Doorslaer E. Equity Commission to Build a Healthier America. report from the SAC or from the sub- in health care finance and delivery. In:cioeconomic status.22 It is time to Culyer S, Newhouse J, eds. Handbook of Washington, DC: Robert Wood Johnson committee to the SAC. Foundation Commission to Build abe explicit that the heart of a Note. The research presented here Health Economics. Amsterdam: North Healthier America; 2009.commitment to addressing health neither has been published nor is being Holland; 2000. considered for publication elsewhere, 28. Jones CP, Hatch A, Troutman A.disparities is a commitment to 12. Sen A. The Idea of Justice. Cambridge, and all research for this manuscript was Fostering a social justice approach to MA: Harvard University Press; 2009.achieving a more just society. j conducted in accord with prevailing health. In: Braithwaite RL, Taylor SE, ethical principles. We have no affilia- 13. Braveman P, Gruskin S. Poverty, Treadwell HM, eds. Health Issues in the tions with or involvement in any orga- equity, human rights and health. Bull World Black Community. 3rd ed. Hoboken, NJ: nization or entity with a direct financial Health Organ. 2003;81(7):539---545. John Wiley & Sons; 2009.About the Authors interest in the subject matter or materials 14. Braveman P, Gruskin S. Defining 29. Gruskin S, Mills EJ, Tarantola D.Paula A. Braveman is with the University discussed in this manuscript. None of the equity in health. J Epidemiol Community History, principles, and practice of healthof California, San Francisco. Shiriki authors received compensation for this Health. 2003;57(4):254---258. and human rights. Lancet. 2007;370Kumanyika is with University of Pennsyl- work. The authors take full responsibil- 15. Braveman P, Starfield B, Geiger HJ. (9585):449---455.vania School of Medicine, Philadelphia. ity for the material. World Health Report 2000: how it 30. Yamin AE. Shades of dignity: ex-Jonathan Fielding is with the University of removes equity from the agenda for ploring the demands of equality in applyingCalifornia, Los Angeles, School of PublicHealth. Thomas LaVeist is with Johns Human Participant Protection public health monitoring and policy. BMJ. human rights frameworks to health. Health No institutional review board approval 2001;323(7314):678---681. 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