Presentation on theme: "What is health equity. What are health disparities"— Presentation transcript:
1What 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, 2013Paula Braveman, MD, MPHProfessor of Family & Community MedicineDirector, Center on Social Disparities in HealthUniversity of California, San Francisco
3What are “health disparities/inequalities”? Differences, variations: descriptive termsMost official U.S. definitions refer only to differences between unspecified groupsBut we really mean: Health differences that are unfair (in a particular way)M. Whitehead: unfair, avoidable, and unjustBut ideas of fairness, avoidability, and justice varySome 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 rightsE.g. in some countries, leaders claim denial of civil rights to women is fair given their unique roles & capabilities
4Are all health differences unfair? Skiers have more arm/leg fractures than non-skiersWomen live longer than menWealthy people in Manhattan have a health problem that wealthy people in Hollywood, CA do notYounger adults are generally healthier than elderlyWhite women are more likely to be diagnosed with breast cancerWho 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?
5What if the causes are not known? African-American newborns are 2 or more times as likely as White newborns to beborn too small (low birth weight)born too early (premature)And these predict infant mortality, childhood disability, and adult chronic diseaseThe causes are not knownCan we call this unfair?Are they unfair?Worse stage-specific survival from breast Ca among black vs white women
6Human rights principles provide guidance Social & economic rights, including the right to achieve the highest attainable standard of healthRights to: education, living standard adequate for health, benefits of progress, participation in societyGovernments should progressively remove obstacles to fulfillment of rights of all, especially for those with more obstaclesNon-discrimination & equality: prohibits actions with intent or effect of discrimination; requires affirmative action
7Which 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?
8Human 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 affiliationImplicit: vulnerability due to history of discrimination, social exclusion or marginalizationExamples: slavery, genocide, hate crimes, expropriation of ancestral lands, targeted marketing of harmful goods, negative media depictions, slursCan 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
9A human rights-based definition of health disparity & health equity A health difference closely linked with social or economic disadvantageHealth 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 exclusionHealth equity: pursuing the highest possible standard of health for all while focusing on those with the greatest social or economic obstacles to health
10A human rights-based definition of health disparity & health equity Equity versus equalityEqual rights for all. Does not mean equal resourcesObligation to focus on thosewith the greatest obstaclesto fulfilling their rights.Obligation to address not onlymedical care but also thesocial determinants that shapeopportunities to be healthy
11Not all health differences are health disparities Not all health differences -- or even all health differences warranting attentionA particular subset of health differences that reflect social injusticePlausibly avoidable, systematic health differences adversely affecting a socially disadvantaged groupMay reflect social disadvantage – but in any case put already disadvantaged groups at further disadvantage with respect to their health
12Concepts and measurement of health disparities and health equity: not just a technical issue Based on valuesEquity is the ethical principle underlying a commitment to reduce disparitiesHealth disparities are the metric by which health equity is assessedImplications for policy and resource allocation in multiple sectors, including medical carePursuing equity requires swimming upstream, against prevailing tides – will encounter resistanceNeed to know where we are headed and whyValues lead us to ask questions about disparities and equity, but need not –and must not-- compromise scientific rigorQuestions about health inequalities (as defined here) and health equity reflect concern for valuesDifference between studying inequalities/equity vs all of epidemiologyStudying equity is challenging wealth and power; swimming against the prevailing tideProfoundly political challenging distribution of power and wealthThis 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 advantagedStudying equity has big technical challenges. But the biggest challenges are not technical – they are political – swimming against the tide. Being strategic (and rigorous)
13Opportunities & Resources Finding solutions to health disparities: Understanding the importance of social factorsEconomic & SocialOpportunities & ResourcesPolicies to promote childand youth developmentand education, infancythrough collegePolicies to promote economic development, reduce poverty,and reduce racial segregationLiving & Working Conditionsin Homes & CommunitiesPolicies to promote healthier homes, neighborhoods, schools and workplacesMedicalCarePersonalBehaviorHEALTHRobert Wood Johnson Foundation Commission to Build a Healthier America
14Finding solutions by understanding how health is transmitted across lifetimes and generations