Health Disparities and Health Equity: The Issue Is Justice

摘要

Eliminating health disparities is a Healthy People goal. Given the diverse and sometimes broad definitions of health disparities commonly used, a subcommittee convened by the Secretary's Advisory Committee for Healthy People 2020 proposed an operational definition for use in developing objectives and targets, determining resource allocation priorities, and assessing progress. Based on that subcommittee's work, we propose that health disparities are systematic, plausibly avoidable health differences adversely affecting socially disadvantaged groups; they may reflect social disadvantage, but causality need not be established. This definition, grounded in ethical and human rights principles, focuses on the subset of health differences reflecting social injustice, distinguishing health disparities from other health differences also warranting concerted attention, and from health differences in general. We explain the definition, its underlying concepts, the challenges it addresses, and the rationale for applying it to United States public health policy. One of 2 overarching goals of Healthy People 2010 1 was “to eliminate health disparities among different segments of the population.” A similar goal to “achieve health equity and eliminate health disparities” was proposed by the Health and Human Services Secretary's Advisory Committee (SAC) for Healthy People 2020. 2 Healthy People 2010 noted that health disparities “include differences that occur by gender, race or ethnicity, education or income, disability, living in rural localities, or sexual orientation.” 1 However, the rationale for identifying disparities in relation to these particular population groups was not articulated. The National Institutes of Health defined health disparities as “differences in the incidence, prevalence, mortality, and burden of diseases and other adverse health conditions that exist among specific population groups in the United States” 3 , 4 ; several other federal agencies have similarly broad definitions. 5 The lack of explicit criteria for identifying disparities in Healthy People 2010 1 and the relatively nonspecific definitions of disparities used by federal agencies 3 , 4 leave considerable room for ambiguity as to what other groups might also be relevant. Furthermore, there has been controversy as to whether definitions of health disparities should imply injustice or simply reflect differences in health outcomes that might apply to any United States population segment. 6 – 8 Different ethical, philosophical, legal, cultural, and technical perspectives may generate different definitions of health disparities or inequalities (the most comparable term outside the United States). 9 – 21 For example, in the United Kingdom, Whitehead defined health inequalities as differences that are unnecessary, avoidable, and unfair. 21 This definition is widely used internationally, where “health inequalities” are assumed to be socioeconomic differences unless otherwise specified; in the United States, however, “health disparities” more often refer to racial or ethnic differences. Effective public policies require clear and contextually relevant operational definitions to support the development of objectives and specific targets, determine priorities for use of limited resources, and assess progress. The need for clear definitions is particularly compelling given the lack of progress toward reducing racial/ethnic and socioeconomic disparities in medical care 22 and health. 23 – 25 Recognizing the practical implications of lack of clarity on this critical issue, the SAC convened a subcommittee to define “health disparity” and “health equity” for use in Healthy People 2020 . 2 The subcommittee members, including both SAC members and external experts, wrote this paper to elaborate on the definitions and explain their rationale. 2 , 26 These definitions ( see the box on the next page ) and the rationale presented are substantively consistent with those adopted by the SAC and recently published in Healthy People 2020 ,2 but reflect some changes in wording. Clarifying these concepts will enable medical and public health practitioners and leaders to be more effective in reducing disparities in medical care and in advocating for social policies (e.g., in child care, education, housing, labor, and urban planning) that can have major impacts on population health. 27 Health Disparities and Health Equity Health disparities are health differences that adversely affect socially disadvantaged groups. Health disparities are systematic, plausibly avoidable health differences according to race/ethnicity, skin color, religion, or nationality; socioeconomic resources or position (reflected by, e.g., income, wealth, education, or occupation); gender, sexual orientation