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

“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 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

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?

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

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

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?

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

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

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

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

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)

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 www.commissiononhealth.org

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