CDE Appendix 1 Literature Review - Central East Local Health ...

The Culture, Diversity and Equity Project: Literature Review
Health Inequality
The term health inequality is used in European contexts to focus the lens more specifically on health inequalities
relating to socio-economic status. This terminology has been ‘officially sanctioned’ in the United Kingdom since the
coming to power of Tony Blair’s Labour government in 1997. It came to replace the much more neutral then in use
term of ‘health variations’ which predominated (when discussed at all) under the Conservative government’s of
Margaret Thatcher and John Major (Exworthy, Blane, and Marmot, 2003).
In keeping with the UK/European perspective, Exworthy et al. (2006) define health inequalities as ‘systematic
disparities in health [status] (or in the major social determinants of health) between groups with
different levels of underlying social ad- vantage/disadvantage,’ including wealth, power, or prestige” (citing
Braveman and Gruskin 2003, p.4). Reflecting European approaches more generally, Mackenbach et al. (2002a)
similarly focus on and define socioeconomic inequalities in health as “systematic differences in morbidity and
mortality rates between individual people of higher and lower socioeconomic status to the extent that these
are perceived to be unfair.”
The (2004) Health Disparities Task Group Discussion Paper for the Public Health Agency of Canada draws a finer
distinction between health inequality and health inequity, describing health inequality as ”the generic term used to
designate differences, variations, and disparities in the health achievements and risk factors of individuals
and groups…that need not imply moral judgment” (Health Disparities Task Group citing Kawachi et al., 2002,
p.56). Health inequalities due to individual biological endowment or the consequences of personal choices would
not qualify, in this view, as health inequities, but rather, count as health inequalities. What should concern public
policy, this discussion paper goes on to suggest, is “health inequalities attributable to modifiable factors,
especially those that are perceived as inequitable” (see more definitions and descriptions of health inequity
below).
Health Inequity
Of all the terms used, health inequity most consistently and strongly implies health disparities that are unjust and/or
thus of moral and political concern. Gardner (2008b) in this light defines health inequities (which he uses
interchangeably with health disparities) as “differences in health outcomes that are avoidable, unfair and
systematically related to social inequality and disadvantage”. The link between health equity, social justice and
ethics is made even more explicit in the World Health Organization’s (2008) Closing the Gap report:
Where systematic differences in health are judged to be avoidable by reasonable action they are, quite
simply, unfair. It is this that we label health inequity. Putting right these inequities and the huge and
remediable differences in health between and within countries is a matter of social justice. Reducing
health inequities is, for the Commission on Social Determinants of Health (hereafter, the Commission),
an ethical imperative (WHO, 2008).
The Health Disparities Task Group (2004) similarly links inequity and injustice, defining health inequities as “those
inequalities in health that are deemed to be unfair or stemming from some form of injustice”. It is the
normative judgement implied by the terminology of health inequity, they argue, that distinguishes it from health
inequality. Precisely because of the normative nature of such judgements the Health Disparities Task Group
emphasize that “science alone cannot determine which inequalities are also inequitable, nor what proportion of an
observed inequality is unjust or unfair” (Health Disparities Task Group, 2004 quoting Kawachi et al., 2002, p.647-
8). For such normative judgements depend upon, among other things,”(a) one’s theories of justice; (b) one’s theories
of society; and (c) one’s reasoning underlying the genesis of health inequalities” (ibid.). An ethical theory of social
justice is thus ultimately required to differentiate unfair from fair differences in health status.
Inequitable distributions of health are most commonly and consistently described and defined as those health
differences that are avoidable, unnecessary and unfair (Whitehead, 1998). Examples of the latter include
“differences in health resulting from health-damaging behaviour not freely chosen, or from exposure to health
hazards in the environment, or from impaired access to healthcare services” (Mackenbach et al., 2002a). Since these
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