5/31/2017 WhatAreHealthDisparitiesandHealthEquity?

WeNeedtoBeClear

PublicHealthRep.2014JanFeb129(Suppl2):58. PMCID:PMC3863701
doi:10.1177/00333549141291S203

WhatAreHealthDisparitiesandHealthEquity?WeNeedtoBeClear
PaulaBraveman,MD,MPH a
a
UniversityofCalifornia,SanFrancisco,SchoolofMedicine,DepartmentofFamilyandCommunityMedicine,CenteronSocialDisparitiesin
Health,SanFrancisco,CA
Correspondingauthor.
Addresscorrespondenceto:PaulaBraveman,MD,MPH,UniversityofCalifornia,SanFrancisco,SchoolofMedicine,DepartmentofFamily
andCommunityMedicine,CenteronSocialDisparitiesinHealth,POBox0943,3333CaliforniaSt.,Ste.365,SanFrancisco,CA94118
0943,Phone:4154766839,Fax:4154765219,braveman@fcm.ucsf.edu.

Copyright2014AssociationofSchoolsandProgramsofPublicHealth

ThisarticlehasbeencitedbyotherarticlesinPMC.

Abstract Goto:

Healthdisparitiesandhealthequityhavebecomeincreasinglyfamiliartermsinpublichealth,but
rarelyaretheydefinedexplicitly.Ambiguityinthedefinitionsofthesetermscouldleadtomisdirectionof
resources.Thisarticlediscussestheneedforgreaterclarityabouttheconceptsofhealthdisparitiesand
healthequity,proposesdefinitions,andexplainstherationalebasedonprinciplesfromthefieldsofethics
andhumanrights.

Ifyoulookuptheworddisparityinadictionary,youwillmostlikelyfinditdefinedsimplyas
difference,variation,or,perhaps,inequality,withoutfurtherspecification.Butwhenthetermhealth
disparitywascoinedintheUnitedStatesaround1990,itwasnotmeanttorefertoallpossiblehealth
differencesamongallpossiblegroupsofpeople.Rather,itwasintendedtodenoteaspecifickindof
difference,namely,worsehealthamongsociallydisadvantagedpeopleand,inparticular,membersof
disadvantagedracial/ethnicgroupsandeconomicallydisadvantagedpeoplewithinanyracial/ethnic
group.However,thisspecificityhasgenerallynotbeenmadeexplicit.UntilthereleaseofHealthyPeople
2020in2010,federalagencieshadofficiallydefinedhealthdisparitiesinverygeneralterms,as
differencesinhealthamongdifferentpopulationgroups,withoutfurtherspecification.1,2Thisarticle
arguesfortheneedtobeexplicitaboutthemeaningofhealthdisparitiesandtherelatedtermhealth
equity,andproposesdefinitionsbasedonconceptsfromthefieldsofethicsandhumanrights.

WHYEXPLICITDEFINITIONSARENEEDED Goto:

Notallhealthdifferencesarehealthdisparities.Examplesofhealthdifferencesthatarenothealth
disparitiesincludeworsehealthamongtheelderlycomparedwithyoungadults,ahigherrateofarm
injuriesamongprofessionaltennisplayersthaninthegeneralpopulation,or,hypothetically,ahigherrate
ofaparticulardiseaseamongmillionairesthannonmillionaires.Whilethesedifferencesareunlikelyto
occupyprominentplacesinapublichealthagenda,therearemanyhealthdifferencesthatareimportant
forasocietytoaddressbutarenothealthdisparities.Forexample,ifthehealthofanentirepopulation
seemedtobegettingworseovertime,oriftherewereaseriousdiseaseoutbreakinanaffluent
communitynotseeninlessaffluentcommunities,thesehealthdifferenceswouldmeritattention,butfor
reasonsotherthanrelevancetohealthdisparitiesorequity.Noneoftheseexamplesreflectswhatisatthe
heartoftheconceptofhealthdisparities:concernsaboutsocialjusticethatis,justicewithrespecttothe
treatmentofmoreadvantagedvs.lessadvantagedsocioeconomicgroupswhenitcomestohealthand
healthcare.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3863701/ 1/4
5/31/2017 WhatAreHealthDisparitiesandHealthEquity?WeNeedtoBeClear

Ambiguityaboutthemeaningofhealthdisparitiesandhealthequitycouldpermitlimitedresourcestobe
directedawayfromtheintendedpurposes.Forexample,ifthesetermsremainvaguelydefined,socially
andeconomicallyadvantagedgroupscouldcooptthetermsandadvocateforresourcestoaddresstheir
advantagedsocialgroup'shealthneeds.

DEFININGHEALTHDISPARITYANDHEALTHEQUITY Goto:

Recognizingtheneedforclarity,HealthyPeople2020definedahealthdisparityas:

aparticulartypeofhealthdifferencethatiscloselylinkedwitheconomic,social,or
environmentaldisadvantage.Healthdisparitiesadverselyaffectgroupsofpeoplewhohave
systematicallyexperiencedgreatersocialoreconomicobstaclestohealthbasedontheirracialor
ethnicgroup,religion,socioeconomicstatus,gender,age,ormentalhealthcognitive,sensory,or
physicaldisabilitysexualorientationorgenderidentitygeographiclocationorother
characteristicshistoricallylinkedtodiscriminationorexclusion.3

Inthisdefinition,economicdisadvantagereferstolackofmaterialresourcesandopportunitiesfor
example,lowincomeorlackofwealth,andtheconsequentinabilitytopurchasegoods,services,and
influence.Socialdisadvantageisabroaderconcept.Whileitincludeseconomicdisadvantage,italso
refersmoregenerallytosomeone'srelativepositioninasocialpeckingorderanorderinwhich
individualsorgroupscanbestratifiedbytheireconomicresources,aswellasbyrace,ethnicity,religion,
gender,sexualorientation,anddisability.Thesecharacteristicscaninfluencehowpeoplearetreatedina
society.IntheHealthyPeopledefinition,environmentaldisadvantagereferstoresidingina
neighborhoodwherethereisconcentratedpovertyand/orthesocialdisadvantagesthatoftenaccompany
it.

Healthequityistheprincipleunderlyingacommitmenttoreduceand,ultimately,eliminatedisparities
inhealthandinitsdeterminants,includingsocialdeterminants.Pursuinghealthequitymeansstrivingfor
thehighestpossiblestandardofhealthforallpeopleandgivingspecialattentiontotheneedsofthoseat
greatestriskofpoorhealth,basedonsocialconditions.

Whatisthebasisforthesedefinitions?Morespecifically,whatisthebasisforsinglingoutacertain
categoryofhealthdifferences,thoselinkedwitheconomic/socialdisadvantage,forspecialattention?
Therearemultiplereasons.First,amassivebodyofevidencestronglylinkseconomic/social
disadvantagewithavoidableillness,disability,suffering,andprematuredeath.49Anotherarticleinthis
supplement10discussessomeofthatevidence.Second,economic/socialdisadvantagecanbeameliorated
bysocialpolicies,suchasminimumwagelaws,progressivetaxation,andstatutesbarringdiscrimination
inhousingoremploymentbasedonrace,gender,disability,orsexualorientation.

Inaddition,thesedefinitionshaveabasisinprinciplesfromthefieldsofethicsandhumanrights.11
Danielsandotherethicistshavepointedoutthathealthisneededforfunctioningineverysphereoflife.
Therefore,theresourcesneededtobehealthyincludingnotonlymedicalcare12butalsohealth
promotinglivingandworkingconditions13shouldnotbetreatedascommoditiessuchasdesigner
clothingorluxurycars.Rather,theyshouldbedistributedaccordingtoneed.Anaversiontohealth
disparitiesreflectswidelyheldsocialvaluesthatcallforeveryonetohaveafairchancetobehealthy,
giventhathealthiscrucialforwellbeing,alonglife,andeconomicandsocialopportunity.

Laws,treaties,andprinciplesfromthefieldofhumanrightsalsoprovideabasisforthesedefinitions.By
now,avastmajorityofcountrieshavesigned(ifnotratified)majorhumanrightsagreementsthatareof
greatrelevancetohealthdisparitiessigningimpliesagreementinprinciple.Whilehumanrights
agreementsarealltoooftenviolated,thisglobalconsensusonfundamentalvalues,developedovera
periodofyears,greatlystrengthensthebasisfordefiningtheconceptofhealthdisparities.Under
internationalhumanrightslawsandagreements,countriesareobligatedtoprotect,promote,andfulfill
thehumanrightsofeveryoneintheirpopulations.Recognizingthatmanycountrieslacktheresourcesto
removeallobstaclestoallrightsforeveryoneimmediately,humanrightsagreementsrequirethat
countriesdemonstrateprogressiverealizationi.e.,theyaremakinggradualprogresstowardrealizing
therightsoftheirpopulations.Ofparticularrelevanceforunderstandinghealthdisparitiesandhealth
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3863701/ 2/4
5/31/2017 WhatAreHealthDisparitiesandHealthEquity?WeNeedtoBeClear

equityistheimplicitobligationtopayparticularattentiontothosesegmentsofthepopulationwho
experiencethemostsocialobstacles.14

Mostlikely,theprinciplethatfirstcomestomindwhenconsideringhumanrightsinrelationtohealthis
therighttohealth,definedastherighttoattainthehighestpossiblestandardofhealth.Ihaveargued
elsewherethat,forthepurposeofmeasurement,thehighestpossiblestandardofhealthcanbereflected
bythelevelofhealthamongthemosteconomicallyandsociallyprivilegedgroupinasociety.11One
couldarguethatthisstandardisconservative.Therighttohealth,however,isnotonlyarighttohealth
care.Alargebodyofknowledge,includingsourcescitedpreviously,indicatesthattheresourcesneeded
tobehealthyincludenotonlyqualitymedicalcare,butalsoeducationandhealthpromotingphysicaland
socialconditionsinhomes,neighborhoods,andworkplaces.Humanrightsprinciplescallforcountriesto
removeobstaclestohealthinanysectorforexample,ineducation,housing,ortransportationand
theyexplicitlycallfortherighttoastandardoflivingnecessarytoprotectandpromotehealth.15,16

Equallyrelevanttohealthdisparitiesarethehumanrightsprinciplesofnondiscriminationandequality.
Accordingtotheseprinciples,everyonehasequalrights,andstatesareobligatedtoprohibitpoliciesthat
haveeithertheintentionortheeffectofdiscriminatingagainstparticularsocialgroups.Itisoftenvery
difficulttoprovewhataperson's(orinstitution's)intentionsvs.actionswere.Inaddition,ata
populationlevel,greaterharmtohealthmaybedoneasaresultofunintentionallydiscriminatory
processesandstructures,17,18evenwhenconsciousintenttodiscriminatenolongerexistsorcanbe
documented.ExamplesofsuchprocessesandstructureswhichpersistasthelegacyofslaveryandJim
Crow,bothofwhichwerelegalandintentionallydiscriminatoryincluderacialsegregation,criminal
justicecodesandpatternsofenforcingthem,andtaxpoliciesthatmakeschoolsdependentonlocal
funding.Theseexamplesmaynolongerreflectconsciousintenttodiscriminate,butneverthelesspersist
andtransmiteconomicandsocialdisadvantagewithhealthconsequencesacrossgenerations.17,18
Becausehumanrightsagreementsandprinciplesprohibitdefacto(unintentionalorstructural)aswellas
intentionaldiscrimination,wedonothavetoknowthecausesofahealthdifferencetocallitahealth
disparity.Healthdisparitiesareinequitable,evenwhenwedonotknowthecauses,becausetheyputan
alreadyeconomically/sociallydisadvantagedgroupatfurtherdisadvantagewithrespecttotheirhealth.
Furthermore,healthisnecessarytoovercomeeconomic/socialdisadvantage.2,11

Healthequityandhealthdisparitiesareintertwined.Healthequitymeanssocialjusticeinhealth(i.e.,no
oneisdeniedthepossibilitytobehealthyforbelongingtoagroupthathashistoricallybeen
economically/sociallydisadvantaged).Healthdisparitiesarethemetricweusetomeasureprogress
towardachievinghealthequity.Areductioninhealthdisparities(inabsoluteandrelativeterms)is
evidencethatwearemovingtowardgreaterhealthequity.Movingtowardgreaterequityisachievedby
selectivelyimprovingthehealthofthosewhoareeconomically/sociallydisadvantaged,notbya
worseningofthehealthofthoseinadvantagedgroups.19

Themostintuitiveandcleardefinitionofhealthinequalities(thetermusedinmostcountries,whereitis
generallyassumedtorefertosocioeconomicdifferencesinhealth)wasdevelopedbyMargaret
WhiteheadintheUnitedKingdom.Shedefinedhealthinequalitiesashealthdifferencesthatare
avoidable,unnecessary,andunjust.20Themoretechnicaldefinitionpresentedherewasdevelopedin
responsetoexperiencerevealingthatdifferentpeoplemayhaveverydifferentideasofwhatisavoidable,
unnecessary,andunjust,andthatadditionalguidanceisoftenneededtokeeppoliciesandprogramson
track.TheWhiteheaddefinition,however,conciselyandeloquentlycapturestheessenceofwhathealth
disparitiesandhealthequityare,andwhywearecommittedtoeliminatingthem.

Footnotes Goto:

TheauthorthanksRabiaAslamandKaitlinArenafortheiroutstandingresearchassistance.

REFERENCES Goto:

1.CarterPokrasO,BaquetC.Whatisahealthdisparity?PublicHealthRep.2002117:42634.
[PMCfreearticle][PubMed]

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3863701/ 3/4
5/31/2017 WhatAreHealthDisparitiesandHealthEquity?WeNeedtoBeClear

2.BravemanPA,KumanyikaS,FieldingJ,LaveistT,BorrellLN,ManderscheidR,etal.Health
disparitiesandhealthequity:theissueisjustice.AmJPublicHealth.2011101(Suppl1):S14955.
[PMCfreearticle][PubMed]

3.HealthyPeople.gov.Disparities[cited2012Nov20]Availablefrom:URL:
http://www.healthypeople.gov/2020/about/disparitiesAbout.aspx.

4.AdlerNE,StewartJ,editors.Thebiologyofdisadvantage:socioeconomicstatusandhealth.Hoboken
(NJ):JohnWiley&Sons2010.[PubMed]

5.WorldHealthOrganization,CommissiononSocialDeterminantsofHealth.Geneva:WHO2008.
Closingthegapinageneration:healthequitythroughactiononthesocialdeterminantsofhealth.CSDH
finalreport.[PubMed]

6.KriegerN.Theostrich,thealbatross,andpublichealth:anecosocialperspectiveorwhyanexplicit
focusonhealthconsequencesofdiscriminationanddeprivationisvitalforgoodscienceandpublic
healthpractice.PublicHealthRep.2001116:41923.[PMCfreearticle][PubMed]

7.VirchowRC.ReportonthetyphusepidemicinUpperSilesia.1848.AmJPublicHealth.
200696:21025.[PMCfreearticle][PubMed]

8.RosenG.Baltimore:JohnsHopkinsUniversityPress1993.Ahistoryofpublichealth.Expandeded.

9.WinslowCE.Povertyanddisease.AmJPublicHealthNationsHealth.194838(1Pt2):17384.
[PMCfreearticle][PubMed]

10.BravemanP,GottliebL.Thesocialdeterminantsofhealth:it'stimetoconsiderthecausesofthe
causes.PublicHealthRep.2014129(Suppl2):1931.[PMCfreearticle][PubMed]

11.BravemanP.Healthdisparitiesandhealthequity:conceptsandmeasurement.AnnuRevPublic
Health.200627:16794.[PubMed]

12.DanielsN.Healthcareneedsanddistributivejustice.PhilosPublicAff.198110:14679.[PubMed]

13.DanielsN,KennedyBP,KawachiI.Whyjusticeisgoodforourhealth:thesocialdeterminantsof
healthinequalities.Daedalus.1999128:21551.[PubMed]

14.BravemanP,GruskinS.Definingequityinhealth.JEpidemiolCommunityHealth.200357:2548.
[PMCfreearticle][PubMed]

15.UnitedNations,OfficeoftheHighCommissionerforHumanRights.InternationalCovenanton
Economic,SocialandCulturalRights.GeneralAssemblyresolution2200A(XXI)1966.Dec16,[[cited
2013Sep13]].Article12.Availablefrom:URL:
http://www.ohchr.org/EN/ProfessionalInterest/Pages/CESCR.aspx.

16.BravemanP.Socialconditions,healthequity,andhumanrights.HealthHumRights.201012:3148.
[PubMed]

17.WilliamsDR,CollinsC.Racialresidentialsegregation:afundamentalcauseofracialdisparitiesin
health.PublicHealthRep.2001116:40416.[PMCfreearticle][PubMed]

18.WilliamsDR,MohammedSA.Discriminationandracialdisparitiesinhealth:evidenceandneeded
research.JBehavMed.200932:2047.[PMCfreearticle][PubMed]

19.WhiteheadM,DahlgrenG.Conceptsandprinciplesfortacklingsocialinequitiesinhealth:levelling
uppart1.Copenhagen:WorldHealthOrganizationRegionalOfficeforEurope2006.

20.WhiteheadM.Theconceptsandprinciplesofequityandhealth.IntJHealthServ.199222:42945.
[PubMed]

ArticlesfromPublicHealthReportsareprovidedherecourtesyofSAGEPublications

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3863701/ 4/4