Social inequities in health are the central focus of this paper. Such inequities concern systematic differences in health status between different socioeconomic groups. But what exactly does that entail? Within any country, differences in health can be observed across the population. Genetic and constitutional variations ensure that the health of individuals varies, as it does for any other physical characteristic. The prevalence of ill health also differs between different age groups, with older people tending to be sicker than younger people, because of the natural ageing process. Biologically, women in older industrialized countries exhibit an advantage in survival over men at every stage of life. Chance also plays a role in everyone’s life, with luck deciding which individuals avoid a particular infectious disease or hazard and which succumb.
Three distinguishing features, when combined, turn mere variations or differences in health into a social inequity in health. They are systematic, socially produced (and therefore modifi able) and unfair.
The first feature is the systematic pattern of the differences in health. These differences are not distributed randomly, but show a consistent pattern across the population. One of the most striking examples is the systematic differences in health between different socioeconomic groups. Mortality and morbidity increase with declining social position, as illustrated in subsequent sections. This social pattern of disease is universal, though its magnitude and extent vary among countries.
The second feature is the social processes that produce health differences, rather than these differences being determined biologically. No Law of Nature, for instance, decrees that the children of poor families should die at twice the rate as that of children born into rich families (Blane et al., 1993), so this health inequity is not fi xed or inevitable. Theoretically, at least, if social processes generate these differences in a country, then these differences should be amenable to alteration by a concerted effort by that country.
The third feature is that social inequities are differences widely considered to be unfair, because they are generated and maintained by what Evans & Peters (2001) have termed “unjust social arrangements” that offend common notions of fairness. Of course, this depends on the meaning attributed to different people to the idea of unfair. Although ideas about what is unfair may differ to a certain degree from place to place, there is much common ground. For example, most (if not all) people in European countries share the view that all children, regardless of social group, should have the same chance of survival. It would be widely considered unfair if the chance of survival was much poorer for the children of some socioeconomic groups, compared with that of others. This is but one illustration of an all-embracing concern across Europe for linking fairness to human rights.
Fairness and human rights
The bias and discrimination that lead to differences in access to the resources and opportunities for health between social groups are unfair. This touches on the special place that health holds in human rights: everyone has the right to enjoy the highest attainable standard of health in their society (WHO, 1946). Health is also a unique resource for achieving other objectives in life, such as better education and employment. Health is therefore a way of promoting the freedom of individuals and societies (Sen, 2000).
It is therefore important for a society to organize its health resources equitably, so that access to those resources are open to everybody. The existence of clear social differentials in health and in their determinants (illustrated in subsequent sections) goes against accepted values of fairness and justice (Daniels, Kennedy & Kawachi, 2000).
In today’s Europe, working out what social differences in health are fair and unfair is unnecessary. Essentially, all systematic differences in health between different socioeconomic groups within a country can be considered unfair and, therefore, classed as health inequities. There is no biological reason for their existence, and it is clear that even systematic differences in lifestyles between socioeconomic groups are to a large extent shaped by structural factors. Summing up briefl y, social inequities in health are directly or indirectly generated by social, economic and environmental factors and structurally infl uenced lifestyles. These determinants of social inequities are all amenable to change.
In the International Covenant on Economic, Social and Cultural Rights, the wording deliberately sets health in the context in which people live (Kälin et al., 2004). For the purpose of taking action, the health status of groups of people who are better off can be used as a practical indicator of the standard of health attainable in any given society and as the standard to which policies that address inequities in health should strive.
Inequality and inequity are synonymous
Earlier papers by the present authors, adopted the phrase inequities in health throughout, while explaining that in some countries, notably the United Kingdom, the phrase inequalities in health was used and had the same meaning. In the intervening years, more European countries have adopted the British terminology, as illustrated by the title of the 2005 EU Summit on Tackling Inequalities in Health. For consistency with other WHO documents, however, the phrase social inequities in health has been retained in this paper. The authors would still like to emphasize, though, that in the public health community the phrase social inequalities in health carries the same connotation of health differences that are unfair and unjust. Indeed, as some European languages have only one word for the two terms, there is no distinction between the two when they are translated.
So what is equity in health?
If inequity in health is unfair and unjust, what then is the converse: equity in health? The concept is related intimately to the central human rights thread that has run right through the key articles of WHO, from its inception in the 1940s to the resolutions of the 21st century. The WHO Constitution (WHO, 1946) asserted back in 1946 that “the highest standards of health should be within reach of all, without distinction of race, religion, political belief, economic or social condition”.
Echoing these sentiments nearly 60 years later, equity in health implies that ideally everyone could attain their full health potential and that no one should be disadvantaged from achieving this potential because of their social position or other socially determined circumstance.
This refers to everyone and not just to a particularly disadvantaged segment of the population. Efforts to promote social equity in health are therefore aimed at creating opportunities and removing barriers to achieving the health potential of all people. It involves the fair distribution of resources needed for health, fair access to the opportunities available, and fairness in the support offered to people when ill.
The outcome of these efforts would be a gradual reduction of all systematic differences in health between different socioeconomic groups. The ultimate vision is the elimination of such inequities, by levelling up to the health of the most advantaged.
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