1. What is health equity. What are health disparities
What is health equity? What are health disparities? And why do the definitions matter?
The Colorado Trust, Denver, January 31, 2013
Paula Braveman, MD, MPH
Professor of Family & Community Medicine
Director, Center on Social Disparities in Health
University of California, San Francisco

2. “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

3. What are “health disparities/inequalities”?
Differences, variations: descriptive terms
Most official U.S. definitions refer only to differences between unspecified groups
But we really mean: Health differences that are unfair (in a particular way)
M. Whitehead: unfair, avoidable, and unjust
But ideas of fairness, avoidability, and justice vary
Some people in US believe it si fair to deny health care to undocumented immigrants and to deny an education to their children.
Many people in the U.S. view health care as something one earns with hard work, not a fundamental human rights
E.g. in some countries, leaders claim denial of civil rights to women is fair given their unique roles & capabilities

4. Are all health differences unfair?
Skiers have more arm/leg fractures than non-skiers
Women live longer than men
Wealthy people in Manhattan have a health problem that wealthy people in Hollywood, CA do not
Younger adults are generally healthier than elderly
White women are more likely to be diagnosed with breast cancer
Who determines what’s fair?
Who determines what’s avoidable?
Is poverty avoidable?
Are some consequences of disability avoidable – e.g., with public investment in ramps & other approaches to increase accessibility?

5. What if the causes are not known?
African-American newborns are 2 or more times as likely as White newborns to be
born too small (low birth weight)
born too early (premature)
And these predict infant mortality, childhood disability, and adult chronic disease
The causes are not known
Can we call this unfair?
Are they unfair?
Worse stage-specific survival from breast Ca among black vs white women

6. Human rights principles provide guidance
Social & economic rights, including the right to achieve the highest attainable standard of health
Rights to: education, living standard adequate for health, benefits of progress, participation in society
Governments should progressively remove obstacles to fulfillment of rights of all, especially for those with more obstacles
Non-discrimination & equality: prohibits actions with intent or effect of discrimination; requires affirmative action

7. Which groups ?
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?
Affluent communities that demonstrate higher rates of certain health problems?
White women’s high incidence of breast cancer?
Men’s shorter life expectancy?
LGBT groups?

8. Human rights principles: Non-discrimination and equality
Vulnerable groups: race or ethnic group, skin color, religion, language, or nationality; socio-economic status; gender, sexual orientation or gender identity; age; disability; geography; political affiliation
Implicit: vulnerability due to history of discrimination, social exclusion or marginalization
Examples: slavery, genocide, hate crimes, expropriation of ancestral lands, targeted marketing of harmful goods, negative media depictions, slurs
Can you think of other characteristics linked with discrimination/marginalization?
What do these groups share in common? Hx of discrim/marginalization; less power, resources, and/or social acceptance/prestige

9. A human rights-based definition of health disparity & health equity
A health difference closely linked with social or economic disadvantage
Health disparities adversely affect groups who have systematically experienced greater social or economic obstacles to health based on characteristics of their group historically linked to discrimination or exclusion
Health equity: pursuing the highest possible standard of health for all while focusing on those with the greatest social or economic obstacles to health

10. A human rights-based definition of health disparity & health equity
Equity versus equality
Equal rights for all. Does not mean equal resources
Obligation to focus on those
with the greatest obstacles
to fulfilling their rights.
Obligation to address not only
medical care but also the
social determinants that shape
opportunities to be healthy

11. Not all health differences are health disparities
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

12. Concepts and measurement of health disparities and health equity: not just a technical issue
Based on values
Equity is the ethical principle underlying a commitment to reduce disparities
Health disparities are the metric by which health equity is assessed
Implications for policy and resource allocation in multiple sectors, including medical care
Pursuing equity requires swimming upstream, against prevailing tides – will encounter resistance
Need to know where we are headed and why
Values lead us to ask questions about disparities and equity, but need not –and must not-- compromise scientific rigor
Questions about health inequalities (as defined here) and health equity reflect concern for values
Difference between studying inequalities/equity vs all of epidemiology
Studying equity is challenging wealth and power; swimming against the prevailing tide
Profoundly political challenging distribution of power and wealth
This approach addresses a number of technical challenges, e.g.:
--Individuals vs groups--Don’t compare predetermined social groups. Compare on health only .
--Which groups. Don’t restrict who the groups are --any avoidable health difference among any groups
--reference group--Compare to the healthiest (vs most socially advantaged)
Compare to the average, not the most advantaged
Studying equity has big technical challenges. But the biggest challenges are not technical – they are political – swimming against the tide. Being strategic (and rigorous)

13. Opportunities & Resources
Finding solutions to health disparities: Understanding the importance of social factors
Economic & Social
Opportunities & Resources
Policies to promote child
and youth development
and education, infancy
through college
Policies to promote economic development, reduce poverty,
and reduce racial segregation
Living & Working Conditions
in Homes & Communities
Policies to promote healthier homes, neighborhoods, schools and workplaces
Medical
Care
Personal
Behavior
HEALTH
Robert Wood Johnson Foundation Commission to Build a Healthier America

14. Finding solutions by understanding how health is transmitted across lifetimes and generations