1. CENTER ON SOCIAL DISPARITIES IN HEALTH University of California, San Francisco The concept & measurement of health inequalities and health equity: not merely a technical matter International Society for Equity in Health Cartagena, Colombia September 26, 2011 Paula Braveman, MD, MPH University of California, San Francisco Professor of Family & Community Medicine Director, Center on Social Disparities in Health

2. CENTER ON SOCIAL DISPARITIES IN HEALTH University of California, San Francisco The concepts & measurement of health inequalities and health equity– not merely a technical matter  Does everyone agree?  What is at stake?  An approach based on ethical and human rights principles

3. “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

4. CENTER ON SOCIAL DISPARITIES IN HEALTH University of California, San Francisco What are “health inequalities”?  Differences, variations: descriptive terms  Most official U.S.A. definitions refer only to differences between unspecified groups  But we really mean: Health differences that are unfair (in a particular way)  Whitehead: unfair, avoidable, and unjust  But notions of fairness, avoidability, and justice vary

5. CENTER ON SOCIAL DISPARITIES IN HEALTH University of California, San Francisco Are all health differences unfair?  Many women have obstetric problems; men do not  Arm/leg fractures more likely in skiers than non-skiers  Wealthy people in Manhattan have some health problems that wealthy people in Hollywood do not  Younger adults are generally healthier than the elderly  Some claim that any avoidable health difference is unfair  Who determines what is avoidable?

6. CENTER ON SOCIAL DISPARITIES IN HEALTH University of California, San Francisco What if the causes are not known?  to have low birth weight  to be born prematurely  which predict infant mortality, childhood disability and development, and adult chronic disease  The causes are not known  Can we call it unfair?  In the USA, compared with European-American (“White”) newborns, African-American (“Black”) newborns are 2 to 3 times as likely:

7. CENTER ON SOCIAL DISPARITIES IN HEALTH University of California, San Francisco Other challenges: Which groups?  The U.S. National Institutes of Health (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?  Higher incidence of breast cancer among White women?  Shorter life expectancy among men?

8. CENTER ON SOCIAL DISPARITIES IN HEALTH University of California, San Francisco Other challenges: Individuals v. groups  A few researchers (then in leadership roles at WHO) once proposed that health inequalities should not be measured by comparing health of pre-selected social groups, e.g., rich - poor  Because it pre-judges causality, obstructing comprehensive inquiry into causes  Their approach: compare individuals (not groups) on health only, then seek explanatory variables  During their tenure, WHO ended an initiative providing technical assistance to countries to collect & analyze health data according to markers of social position  Removed fairness & justice from the agenda for health monitoring

9. CENTER ON SOCIAL DISPARITIES IN HEALTH University of California, San Francisco Other challenges: the reference group for a health equity comparison  Some propose using the average as the reference group, or the healthiest, regardless of their social characteristics  Active dispute now in some U.S. public health agencies  What is wrong with using the population average –or the healthiest-- as the reference group?  Average underestimates inequalities where a higher % of population are disadvantaged  Many reasons –including biologic--for healthiest group to be healthiest

10. CENTER ON SOCIAL DISPARITIES IN HEALTH University of California, San Francisco Human rights principles provide guidance to address these challenges  The right to achieve the highest attainable standard of health  Rights to: education, living standard adequate for health, benefits of progress  All rights are inter-connected and indivisible  Ratifying human rights agreements obligates governments to progressively remove obstacles to realizing all rights  Particularly for groups who have more obstacles

11. CENTER ON SOCIAL DISPARITIES IN HEALTH University of California, San Francisco Relevant human rights principles, e.g.: Non-discrimination and equality  All persons have equal rights and should be able to realize all their rights without discrimination  Including de facto (unconscious, institutional) discrimination – not just deliberate, inter-personal  Prohibit policies with either intent or effect of discrimination  Affirmative action is needed to achieve equal rights for vulnerable groups

12. CENTER ON SOCIAL DISPARITIES IN HEALTH University of California, San Francisco Human rights principles: Non-discrimination and equality  Specifies vulnerable groups: defined by race or ethnic group, skin color, religion, language, or nationality; socioeconomic resources or position; gender, sexual orientation or gender identity; age; physical, mental, or emotional disability or illness; geography; political or other affiliation  Implicit: vulnerability due to history of discrimination or marginalization, lower social position

13. A rights-based definition of health inequality  A health difference closely linked with social or economic disadvantage  Health disparities adversely affect groups of people who have systematically experienced greater social or economic obstacles to health based on their  racial or ethnic group; religion; socioeconomic status; gender; mental health; cognitive, sensory, or physical disability; sexual orientation or gender identity; or other characteristics historically linked to discrimination or exclusion

14. A rights-based definition of health inequalities  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

15. CENTER ON SOCIAL DISPARITIES IN HEALTH University of California, San Francisco Challenges addressed: Burden of proof regarding causation  The causes of many important health inequalities (e.g., racial disparities in low birth weight, premature birth or in stage-specific breast cancer survival) are unknown  Regardless of causes, health inequalities are unfair because they put already disadvantaged groups at further disadvantage on health  Health inequalities are further obstacles to achieving rights

16. CENTER ON SOCIAL DISPARITIES IN HEALTH University of California, San Francisco Challenges addressed: Groups or individuals? Which groups?  Compare groups with different levels of social advantage: resources, power, prestige/acceptance  Human rights principles define the groups  Racial/ethnic, religious, or tribal  Socioeconomic (income/wealth, education, occupation)  Gender, gender identity, sexual orientation, age, mental or physical disability/illness, geographic  Implicit: groups that have historically experienced discrimination or marginalization  Appropriate groups verifiable based on evidence of wealth, power (e.g., high political/executive office), social inclusion (e.g., hate crime victims).

17. CENTER ON SOCIAL DISPARITIES IN HEALTH University of California, San Francisco Measurement challenges: The reference group  The most socially privileged group (greatest power, wealth, prestige), e.g.,  High income/wealthy individuals, households, or neighborhoods  Most privileged racial/ethnic group  Indicates what should be possible for all groups (the “highest attainable standard of health”)  The population average is too low a standard, especially where large proportions are disadvantaged  The healthiest group may be healthiest for reasons not reflecting social justice

18. CENTER ON SOCIAL DISPARITIES IN HEALTH University of California, San Francisco Contributions of a human rights framework  Addresses de facto discrimination/exclusion  Sets benchmark at highest attainable standard of health  Entitlement v. charity  Addresses multiple dimensions of material and social deprivation and disadvantage  Poverty as well as race-based and other discrimination and their physical and psychosocial consequences  Supports addressing inequalities in social determinants of health (rights to education, living standard adequate for health, social participation…)  Reflects global consensus on values and concepts

19. CENTER ON SOCIAL DISPARITIES IN HEALTH University of California, San Francisco Concepts and measurement of health inequalities and health equity: not just a technical issue  Based on values  Equity is the ethical principle underlying a commitment to reduce inequalities  Health inequalities are the metric by which health equity is assessed  Human rights principles can guide analysis, measurement, and action  Implications for policy agendas, resource allocation, & accountability  Inherently political