Week 6 Discussion

Health Disparities and Health Equity: The Issue Is Justice Eliminating health dis-

parities is a Healthy Peo-

ple goal. Given the diverse

and sometimes broad defi-

nitions of health disparities

commonly used, a sub-

committee convened by the

Secretary’s Advisory Com-

mittee for Healthy People

2020 proposed an opera-

tional definition for use in

developing objectives and

targets, determining re-

source allocation priorities,

and assessing progress.

Based on that subcom-

mittee’s work, we propose

that health disparities are

systematic, plausibly avoid-

able health differences ad-

versely affecting socially

disadvantaged groups; they

may reflect social disad-

vantage, but causality need

not be established. This def-

inition, grounded in ethical

and human rights princi-

ples, focuses on the subset

of health differences re-

flecting social injustice,

distinguishing health dis-

parities 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. (Am J Public Health.

2011;101:S149–S155. doi:10.

2105/AJPH.2010.300062)

Paula A. Braveman, MD, MPH, Shiriki Kumanyika, PhD, MPH, Jonathan Fielding, MD, MPH, MA, MBA, Thomas LaVeist, PhD, Luisa N. Borrell, DDS, PhD, Ron Manderscheid, PhD, and Adewale Troutman, MD, MPH, MA

ONE OF 2 OVERARCHING

goals of Healthy People 20101 was ‘‘to eliminate health disparities among different segments of the population.’’ A similar goal to ‘‘achieve health equity and elimi- nate health disparities’’ was pro- posed by the Health and Human Services Secretary’s Advisory Committee (SAC) for Healthy Peo- ple 2020.2 Healthy People 2010 noted that health disparities ‘‘in- clude differences that occur by gender, race or ethnicity, educa- tion or income, disability, living in rural localities, or sexual orienta- tion.’’1 However, the rationale for identifying disparities in relation to these particular population groups was not articulated. The National Institutes of Health de- fined health disparities as ‘‘differ- ences in the incidence, prevalence, mortality, and burden of diseases and other adverse health condi- tions 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 20101 and the relatively nonspecific definitions of disparities used by federal agencies3,4 leave considerable room for ambiguity as to what other groups might also be rele- vant.

Furthermore, there has been controversy as to whether defini- tions of health disparities should imply injustice or simply reflect differences in health outcomes that might apply to any United States population segment.6---8 Dif- ferent ethical, philosophical, legal,

cultural, and technical perspec- tives may generate different defi- nitions of health disparities or in- equalities (the most comparable term outside the United States).9---21

For example, in the United King- dom, Whitehead defined health inequalities as differences that are unnecessary, avoidable, and un- fair.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 priori- ties for use of limited resources, and assess progress. The need for clear definitions is particularly compelling given the lack of prog- ress toward reducing racial/ethnic and socioeconomic disparities in medical care22 and health.23---25

Recognizing the practical implica- tions 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 elab- orate on the definitions and ex- plain their rationale.2,26 These defi- nitions (see the box on the next page) and the rationale presented are substantively consistent with those adopted by the SAC and re- cently 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 dis- parities 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 popu- lation health.27

UNDERLYING VALUES AND PRINCIPLES

The concepts of health dispar- ities and health equity are rooted in deeply held American social values and pragmatic consider- ations, as well as in internationally recognized ethical and human rights principles.9 Drawing on ethical and human rights concepts, key principles underlying the concepts of health disparities and health equity include the following:

All people should be valued equally. This concept was artic- ulated by Jones et al.28 as foun- dational to the concept of eq- uity. Equal worth of all human beings is at the core of the human rights principle that all human beings equally possess certain rights.29,30

Health has a particular value for individuals because it is essential to an individual’s well-being and ability to participate fully in the workforce and a democratic society. Ill health means potential suffering, disability, and/or loss of life, threatens one’s ability to earn a living, and is an obstacle to fully expressing one’s views and engaging in the political

TOWARDS ENVIRONMENTAL JUSTICE AND HEALTH EQUITY

Supplement 1, 2011, Vol 101, No. S1 | American Journal of Public Health Braveman et al. | Peer Reviewed | Environmental Justice | S149

process. The Nobel Laureate economist Amartya Sen31

viewed health as a fundamental capability required to function in society; similarly, ill health can be a barrier to fully re- alizing one’s human rights. Because ill health can be an obstacle to overcoming disad- vantages, health disparities, which further disadvantage so- cially disadvantaged groups, seem particularly unfair. Nondiscrimination and equality. Every person should be able to achieve his/her optimal health status, without distinction based on race or ethnic group, skin color, religion, language, or na- tionality; socioeconomic re- sources or position; gender, sexual orientation, or gender identity; age; physical, mental, or emotional disability or ill- ness; geography; political or other affiliation; or other char- acteristics that have been linked historically to discrimination or marginalization (exclusion from social, economic, or political opportunities). The groups rep- resented by these characteristics substantively agree with those specified by the United Nations Committee on Economic, Social and Cultural Rights as vulnera- ble groups whose rights are at particular risk of being unreal- ized, due to historic discrimina- tion.32 This directly reflects the human rights principles of nondiscrimination and equality; nondiscrimination includes not only intentional but also unintentional or de facto discrimination, meaning dis- criminatory treatment embed- ded in structures and institu- tions, regardless of whether there is conscious intent to dis- criminate.32,33 The late philos- opher John Rawls19 advanced the concept of a society’s ethical

obligation to maximize the well- being of those worst off. An aversion to discrimination is also firmly rooted in United States policies, as exemplified by the Civil Rights Act of 1964 prohibiting discrimination on the basis of race, color, or na- tional origin; the 1954 Brown vs. Board of Education decision desegregating schools; the Hill Burton Act of 1946 prohibiting hospitals receiving federal funds from discriminating on the basis of race, color, or creed; and the Americans with Disabilities Acts of 1990 and 2008 prohibiting discrimination on the basis of physical or mental disability. Health is also of special impor- tance for society because a na- tion’s prosperity depends on the entire population’s health. Healthy workers are more pro- ductive and generate lower an- nual medical care costs.34---36

A healthier population has more workers available for the workforce. Health can facilitate political participation, which is essential for democracy. Rights to health and to a standard of living adequate for health. In- ternational human rights agree- ments, to which virtually all countries are signatories, obligate

governments to respect, protect, fulfill, and promote all human rights of all persons, including the ‘‘right to the highest attain- able standard of health’’ and the right to a standard of living adequate for health and well- being. Governments must dem- onstrate good faith in progres- sively removing obstacles to re- alizing these rights.29 The United States signed but did not ratify the International Covenant on Economic, Social, and Cultural Rights, which articulated the right to health. Signing a treaty, however, is considered an en- dorsement of its principles and reflects acceptance of a good faith commitment to honor its contents. The ‘‘right to health’’ (i.e., ‘‘the right of everyone to the enjoyment of the highest attain- able standard of physical and mental health’’37) is ‘‘not to be understood as a right to be heal- thy,’’ because too many factors beyond states’ control influence health. Rather, it is ‘‘the right to a system of health protection which provides equality of op- portunity to enjoy the highest attainable level of health.’’ It in- cludes the right to equal access to cost-effective medical care as well as to child care, education,

housing, environmental protec- tion, and other factors that are also crucial to health and well- being.38

Health differences adversely af- fecting socially disadvantaged groups are particularly unac- ceptable because ill health can be an obstacle to overcoming social disadvantage. This consideration resonates with common sense notions of fairness, as well as with ethical concepts of justice, notably, the concept that need should be a key determinant of resource allocation for health, and Rawls’ notion of the obli- gation to maximize the well- being of those worst off.39

Sen noted as a ‘‘particularly se- rious . . . injustice . . . the lack of opportunity that some may have to achieve good health because of inadequate social arrangements. . . .’’40 Sen argued that health is a prerequisite for the capability to function nor- mally in society.31 It is therefore particularly unjust that those who are socially disadvantaged should also experience addi- tional obstacles to opportunity based on having worse health. Ratifying human rights agree- ments obliges governments to direct special effort toward

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, gender identity; age, geography, disability, illness, political or other affiliation; or other characteristics associated with discrimination or marginalization. These categories reflect social advantage or disadvantage when they determine an individual’s or group’s position in a social hierarchy (see the box on the next page).

Health disparities do not refer generically to all health differences, or even to all health differences warranting focused attention. They are a specific subset of health differences of particular relevance to social justice because they may arise from intentional or unintentional discrimination or marginalization and, in any case, are likely to reinforce social disadvantage and vulnerability.

Disparities in health and its determinants are the metric for assessing health equity, the principle underlying a commitment to reducing disparities in health and its determinants; health equity is social justice in health.

TOWARDS ENVIRONMENTAL JUSTICE AND HEALTH EQUITY

S150 | Environmental Justice | Peer Reviewed | Braveman et al. American Journal of Public Health | Supplement 1, 2011, Vol 101, No. S1

equalizing the rights of vulner- able groups facing more obsta- cles to realizing their rights. A nonexhaustive list of vulnerable groups is specified in human rights documents on non- discrimination and equal- ity.32,37,41,42

The resources needed to be healthy (i.e., the determinants of health, including living and working conditions necessary for health, as well as medical care) should be distributed fairly. To do so requires considering need (along with capacity to benefit16

and efficiency17) rather than ability to pay or influence in society.17 This principle, along with principles cited previously, reflects the ethical notion of distributive justice (a just distri- bution of resources needed for health) and the human rights principles of nondiscrimination and equality, as well as the right to a standard of living ade- quate for health. Investments in medical care intended to reduce disparities must be weighed against other poten- tially more effective invest- ments that address disparities in other health determinants.38

Health equity is the value under- lying a commitment to reduce and ultimately eliminate health dis- parities. It is explicitly men- tioned in the Healthy People 20202 objectives. Health eq- uity means social justice with respect to health and reflects the ethical and human rights con- cerns articulated previously. Health equity means striving to equalize opportunities to be healthy. In accord with the other ethical principles of be- neficence (doing good) and nonmalfeasance (doing no harm), equity requires con- certed effort to achieve more rapid improvements among

those who were worse off to start, within an overall strategy to improve everyone’s health. Closing health gaps by worsen- ing advantaged groups’ health is not a way to achieve equity. Reductions in health disparities (by improving the health of the socially disadvantaged) are the metric by which progress to- ward health equity is measured.

HEALTH DISPARITIES: DEFINITION AND RATIONALE

We briefly define health dis- parities and health equity (see the box on the previous page), elabo- rating further and explaining in this section. We also discuss social disadvantage, a key concept for understanding disparities and eq- uity (see the box on this page). Health disparities are systematic, plausibly avoidable health differ- ences adversely affecting socially disadvantaged groups. They may reflect social disadvantage,

although a causal link need not be demonstrated. Differences among groups in their levels of social advantage or disadvantage, which can be thought of as where groups rank in social hierarchies, are indicated by measures reflecting the extent of wealth, political or economic influence, prestige, respect, or social accep- tance of different population groups.

Systematic But Not

Necessarily Causal Links With

Social Disadvantage

As noted by Starfield,45 health disparities are systematic, that is, not isolated or exceptional find- ings. Health disparities are sys- tematically linked with social dis- advantage, and may reflect social disadvantage, although a causal link does not need to be demon- strated. Whether or not a causal link exists, health disparities ad- versely affect groups who are al- ready disadvantaged socially, put- ting them at further disadvantage with respect to their health,

thereby making it potentially more difficult to overcome social disad- vantage. This reinforcement or compounding of social disadvan- tage is what makes health dispar- ities relevant to social justice even when knowledge of their causa- tion is lacking. It is important to define health disparities without requiring proof of causality, be- cause there are important health disparities for which the causes have not been established, but which deserve high priority based on social justice concerns. For example, the large Black---White disparity in low birth weight and premature birth strongly pre- dicts disparities in infant mortality and child development, and likely in adult chronic disease.46

Although the causes of racial disparity in birth outcomes are not established,46 credible scientific sources have identified biologi- cal mechanisms that plausibly contribute to the disparities,46---50

which reflect phenomena shaped by social contexts and thus are, at least theoretically, avoidable.

Social Disadvantage

Health disparities and health equity cannot be defined without defining social disadvantage. Social disadvantage refers to the unfavorable social, economic, or political conditions that some

groups of people systematically experience based on their relative position in social hierarchies. It means restricted ability to participate fully in society and enjoy the benefits of progress. Social disadvantage is reflected, for example, by low levels of wealth, income, education, or occupational rank, or by less representation at high levels of political office. Criteria for social disadvantage can be absolute (e.g., the federal poverty threshold in the United States is based on an estimate of the income needed to obtain a defined set of basic necessities for a family of a given size)43 or relative (e.g., poverty levels in a number of European countries are defined in relation to the median income, e.g., less than 50% of the median income).44

Not all members of a disadvantaged group will necessarily be (uniformly) disadvantaged, and not all socially disadvantaged groups will necessarily manifest measurable adverse health consequences. The extent (whether in a single or multiple domains), depth (severity), and duration (e.g., across multiple generations) of disadvantage matter. Social disadvantage is different from unavoidable physical disadvantage due to, for example, an unavoidable physical disability. However, when disabled persons are put at an unnecessary disadvantage in society due to lack of feasible supports (e.g., accessible public buildings and transportation) or to discrimination against them in hiring for work that they could perform, this would constitute social disadvantage, reflecting discriminatory treatment, whether intentional or unintentional.

TOWARDS ENVIRONMENTAL JUSTICE AND HEALTH EQUITY

Supplement 1, 2011, Vol 101, No. S1 | American Journal of Public Health Braveman et al. | Peer Reviewed | Environmental Justice | S151

Plausibly Avoidable

Differences in Health Given

Sufficient Political Will

It must be plausible, but not

necessarily proven, that policies

could reduce the disparities, in-

cluding not only policies affecting

medical care but also social poli-

cies addressing important non-

medical determinants of health

and health disparities, such as a

decent standard of living; a level of

schooling permitting full social

participation, including participa-

tion in the workforce and political

activities; health-promoting living

and working conditions, includ-

ing both social and physical envi-

ronments; and respect and social

acceptance.23,51 This criterion

addresses the issue of avoidability,

which is central to Whitehead’s

definition of health inequalities; it

strives for more specificity about

avoidability and to clarify the bur-

den of proof regarding causality.21

Avoidability can be highly sub- jective. For example, one person may believe that ill health caused by poverty is avoidable; another, however, may believe that both poverty and ill health among the poor are inevitable; hence, these disparities are unavoidable. Ac- cording to the proposed definition, the criterion is whether the given condition is theoretically avoidable, based on current knowledge of plausible causal pathways and bi- ological mechanisms, and assuming the existence of sufficient political will. The more solid the knowl- edge, the more reasonable and politically viable it will be to invest resources in interventions; feasi- bility, costs, and potentially harm- ful unintended consequences must be considered. Without firm knowledge to guide specific inter- ventions, pursuing health equity would require supporting research on how to intervene effectively

and efficiently to reduce important disparities.

Worse Health Among Socially

Disadvantaged Groups

Socially disadvantaged groups are defined a priori, according to criteria consistent with human rights principles regarding non- discrimination and equality. Health disparities and equity should be central considerations for public policy relevant to health, but they are not the only considerations. Other legitimate considerations include the mag- nitude of impact and proportion of the population affected, as well as efficiency in the use of resources. If a more socially advantaged group happens to fare worse on a particular health indicator, this may be a very im- portant issue that public health or other sectors should energeti- cally address; but it is not part of a ‘‘health disparities’’ agenda, which focuses on improving the health of socially disadvantaged groups.

The Need to Reduce

Disparities in the

Determinants of Health

Health determinants include not only medical care but also the quality of the social and physical conditions in which people live, work, learn, and play.23,51,52

Evidence of disparities in health determinants is thus relevant to assessing disparities in health. Society will generally be more motivated to address health dif- ferences that appear to result from modifiable circumstances over which individuals may have little control21,53; for example, the quality of local schools, ex- posure to pollution or crime, or absence of stores selling nu- tritious food in one’s neighbor- hood.

Disadvantaged Groups Are

Not Necessarily Uniformly

Disadvantaged

Internationally recognized hu- man rights documents provide guidance on which groups are disadvantaged. Although health disparities are systematic, a so- cially disadvantaged group will not necessarily fare worse on all health indicators, and might fare better on some. For example, non- Hispanic European American or White (hereafter ‘‘White’’) women over age 40 have higher incidence of breast cancer than non-His- panic African American or Black (hereafter ‘‘Black’’) women,54 and babies born to Hispanic immigrant women often have more favorable birth weights than those born to non-Hispanic Whites.55 Neither of these differences––although both deserve public health attention–– would be a health disparity by the proposed definition. Regardless of this type of exception in relation to a health outcome, Whites as a group are more socially advan- taged than Blacks and Hispanics, as data on income, wealth, educa- tion, occupations, and political office have documented.56---58

Furthermore, on most health indi- cators, including breast cancer mor- tality, White women are healthier than Black women.59 Similarly, higher rates of a preventable illness in1of 2 affluent geographic regions would warrant public health action, but not as a health disparities concern.

The fact that not all members of a disadvantaged group (e.g., Blacks) appear to be severely dis- advantaged (e.g., we have a Black United States President, and some Blacks are highly educated, in high professional positions, and/or wealthy) does not contra- dict considering that group as generally disadvantaged. The

issue is whether the group has been on the whole more disadvantaged than Whites. Ample evidence has documented a longstanding pattern of less wealth,60,61 lower incomes, lower educational attainment, and under-representation in positions of high occupational rank56 and financial and political power62

among Blacks as a group com- pared with Whites. Despite an end to legal racial segregation decades ago, racial residential segregation persists and with it, de facto edu- cational segregation, condemning many Black children to poor quality schools. This reduces their chances of obtaining good jobs with adequate income as adults, perpetuating social disadvantage across generations.63,64

Similarly, although many United States women are affluent and some now hold high profes- sional and political offices, as a group, they are more likely than men to be poor,65 to earn less at a given educational level,66

and to be underrepresented in high political office.67 Human rights documents on nondiscrim- ination explicitly name women as a vulnerable group warranting special protection from discrimi- nation. Patterns suggesting clini- cally unjustified underreceipt of certain cardiac treatments by women compared with men68

would reflect a gender disparity in a determinant of health (medical care, in this instance). Shorter life expectancy among men in general, if likely avoid- able, would clearly be an issue of public health importance based on the magnitude of potential population impact. However, men as a group have more wealth, influence, and prestige, so this difference would not be a social injustice and, therefore, not a health disparity or equity issue.

TOWARDS ENVIRONMENTAL JUSTICE AND HEALTH EQUITY

S152 | Environmental Justice | Peer Reviewed | Braveman et al. American Journal of Public Health | Supplement 1, 2011, Vol 101, No. S1

Health Disparities as the

Metric to Assess Progress

Toward Health Equity

The stated criteria permit the assessment of measurable prog- ress toward greater health equity. Systematic associations with social disadvantage can be identified by observing a repeated pattern of correlations between measures of social disadvantage and a health outcome. Social advantage and disadvantage can be measured by comparing populations on factors such as levels of wealth, income, educational attainment, or occu- pational rank, for example (see the box on page S151). Demonstrating that a given disparity is plausibly avoidable and can be reduced by policies requires being able to de- scribe, at least in general terms, 1 or more potential causal pathways that are consistent with current scientific knowledge; it does not require definitively establishing either the causation of the dispar- ity or proving the effectiveness of existing interventions to reduce it. Guidelines for measuring health disparities are available.9,69---73

Increasingly, the term ‘‘health inequity’’21,74,75––the opposite of health equity––is being used in- stead of ‘‘health disparity’’ to cap- ture explicitly the moral dimension and differentiate health differences thought to reflect injustice from health differences in general. Ex- amples of health differences that would not be considered health disparities according to our defi- nitions (see the box on page S150) include: elderly adults generally having worse health than noneld- erly adults; skiers being at higher risk of long-bone fractures than nonskiers; and men not having obstetric problems, whereas women do. Both ‘‘health disparity’’ and ‘‘health inequity’’ have their place in the public health lexicon.

Health inequity, however, is a forceful term tending to imply a strong judgment about causality, which may be difficult to support in many cases that nevertheless de- serve attention as health disparities (i.e., health differences adversely affecting socially disadvantaged groups) regardless of their causa- tion. As with health equity, mea- suring health inequity relies on health disparities as the metric.

Health Disparity: Not Just

a Health Difference

Interpreting the term ‘‘health disparities’’ as any health differ- ences among any population group, as has been done by some federal agencies, encompasses the entire domain of epidemiology, which is the study of the distribu- tion of diseases and risk factors across different populations. We have argued that the term health disparities should be used advis- edly, in the spirit of the movement for social justice from which the term emerged, to refer to a partic- ular subset of differences in health that meet well-specified criteria of specific relevance to social jus- tice. The definitions proposed here were designed to clarify the con- cepts of health disparities and health equity in ways that could stand up to rigorous conceptual scrutiny as a basis for guiding policy and practice and ensuring accountability, which requires clear criteria for measure- ment.9,69,70 To achieve the de- sired rigor, the full versions of the proposed definitions are complex and technical and will not be suit- able for all audiences; for many audiences, it may be most appro- priate to define health disparities simply as worse health among socially disadvantaged groups and then elaborate as necessary, drawing on the more comprehen- sive form of the definitions.

Limitations

These definitions do not pro- vide numerical cutoffs for deter- mining disadvantage. Nor do they remove completely the need to exercise judgment based on values that are likely to vary across in- dividuals and societies. It is difficult to imagine reasonable definitions of these concepts, however, that would provide rigid cutoffs, would completely pre- clude the exercise of judgment, and would leave no room for contention. The proposed defini- tions do not clarify whether the reference group for making eq- uity/disparities comparisons should be the most advantaged group in one’s country or in the world; using one’s country as the reference point may ignore the better health achieved by advan- taged populations in other parts of the world.

Challenges Addressed

The definitions address major challenges, such as identifying the social groups to be compared and specifying the general criteria for appropriate reference groups for these comparisons.18 These chal- lenges have arisen when consid- ering health disparity or equity issues, with serious implications for resource allocation. These definitions remove the need to establish the causality and avoid- ability of each health difference for it to qualify as a health disparity worthy of special attention. To ad- dress the difficult issue of causality, our definitions acknowledge that a health disparity may or may not arise from social disadvantage, but it must adversely affect members of socially disadvantaged groups; this can be assessed using epidemiologic data revealing repeated and perva- sive associations between health indicators and measures of social

advantage. The causes need not be known definitively, if it is biologi- cally plausible that the difference could be reduced by policies. These definitions also ground the concepts of health disparities and health equity in internationally recognized principles from the fields of ethics and human rights, giving them universality and du- rability. Although human rights are often honored more in the breach than in the observance, they are a powerful resource in that they represent a global con- sensus on values. This consensus can be an important point of ref- erence in national and local de- bates on policies and practice in the United States. It would be naı̈ve to think that achieving con- sensus on a definition would ob- viate the need for constant vigi- lance to ensure that the agenda for research and action on health dis- parities remains on track and true to the essence of the definition; however, having a clear definition is crucial.

The Issue is Justice

Could this approach––putting health disparities within the broader context of ethics and hu- man rights––jeopardize the limited resources allocated to specifically address racial/ethnic disparities, by spreading these resources more thinly among other disadvantaged groups? Would broadening the definition make the concept too abstract and therefore less com- pelling to the public and policy- makers? We concluded that the struggle for racial justice, in which efforts to eliminate racial/ethnic disparities in health are crucial, has far more to gain than to lose from making these principles ex- plicit. The relevant ethical and human rights principles support prioritizing attention to those fac- ing the greatest obstacles, and

TOWARDS ENVIRONMENTAL JUSTICE AND HEALTH EQUITY

Supplement 1, 2011, Vol 101, No. S1 | American Journal of Public Health Braveman et al. | Peer Reviewed | Environmental Justice | S153

ample evidence has documented the multiple and often crushing obstacles faced by members of disadvantaged racial/ethnic groups in the United States, in some cases for centuries. These principles can protect initiatives to address racial/ethnic as well as other disparities in health from a range of potential challenges that constitute real threats.

Previous official approaches to defining health disparities in the United States have avoided being explicit about values and princi- ples, perhaps for fear of stirring political opposition, because of genuine differences in values or because of the prevailing ethos that enjoins researchers to avoid the realm of values that might compromise the integrity of their science. Scientists, like all others, should be guided by ethical and human rights values. The first decade of the 21st century has ended with little if any evidence of progress toward eliminating health disparities by race or so- cioeconomic status.22 It is time to be explicit that the heart of a commitment to addressing health disparities is a commitment to achieving a more just society. j

About the Authors Paula A. Braveman is with the University of California, San Francisco. Shiriki Kumanyika is with University of Pennsylvania School of Medicine, Philadelphia. Jonathan Fielding is with the University of California, Los Angeles, School of Public Health. Thomas LaVeist is with Johns Hopkins Bloomberg School of Public Health, Baltimore, MD. Luisa N. Borrell is with Lehman College, City University of New York, New York. Ron Manderscheid is with the National Association of County Behavioral Health and Developmental Disability Directors, Washington, DC. Adewale Troutman is with the Louisville Metro Department of Public Health and Wellness, Louisville, KY.

Correspondence should be sent to Paula A. Braveman, MD, MPH, Director/Professor, Center on Social Disparities in Health, University of California, San Francisco,

3333 California St., Suite 365, San Francisco, CA 94118 (e-mail: [email protected]). Reprints can be ordered at http://www.ajph. org by clicking the ‘‘Reprints/Eprints’’ link.

This article was accepted November 1, 2010.

Contributors All the authors participated conceptually in developing the recommendations to the Secretary’s Advisory Committee (SAC) on Healthy People 2020, which were the starting point for this article, and all authors contributed ideas, reviewed drafts, and made comments that shaped this article in important ways. P. A. Braveman conceived the initial idea for the article, wrote initial drafts, and wrote most revisions for coauthors’ review, based on their comments. S. Kumanyika also played a major role in writing the text and a lead role in responding to external reviewer comments. J. Fielding, T. LaVeist, L.N. Borrell, R. Manderscheid, and A.Troutman also contributed conceptually and participated in substantive revisions throughout the process.

Acknowledgments We wish to thank Karen Simpkins, MLS, and Colleen J. Barclay, MPH, for their assistance with research. Written permis- sion has been obtained from all persons named here. The authors take full re- sponsibility for the contents of this paper as individuals. This article is not an official report from the SAC or from the sub- committee to the SAC.

Note. The research presented here neither has been published nor is being considered for publication elsewhere, and all research for this manuscript was conducted in accord with prevailing ethical principles. We have no affilia- tions with or involvement in any orga- nization or entity with a direct financial interest in the subject matter or materials discussed in this manuscript. None of the authors received compensation for this work. The authors take full responsibil- ity for the material.

Human Participant Protection No institutional review board approval was required.

References 1. US Department of Health and Human Services. Office of Disease Pre- vention and Health Promotion. Healthy People 2010: Understanding and im- proving health. 2nd ed. Washington, DC: US Government Printing Office; 2000.

2. US Department of Health and Hu- man Services. Office of Disease Preven- tion and Health Promotion. Healthy People

2020, November 2010. Available at: http://www.healthypeople.gov/2020/ about/disparitiesAbout.aspx. Accessed April 8, 2011.

3. National Institute of Arthritis and Musculoskeletal and Skin Diseases. Strate- gic plan for reducing health disparities. Available at: http://www.niams.nih.gov/ About_Us/Mission_and_Purpose/strat_ plan_hd.asp. Accessed September 7, 2010.

4. National Cancer Institute. Health disparities defined. Available at: http:// crchd.cancer.gov/disparities/defined.html. Accessed September 7, 2010.

5. Carter-Pokras O. What is a ‘‘health disparity’’? Public Health Rep. 2002;117: 426---434.

6. Jones CM. The moral problem of health disparities. Am J Public Health. 2010;100(suppl 1):S47---S51.

7. Bloche MG. Health care disparities--- science, politics, and race. N Engl J Med. 2004;350(15):1568---1570.

8. Steinbrook R. Disparities in health care---from politics to policy. N Engl J Med. 2004;350(15):1486---1488.

9. Braveman P. Health disparities and health equity: concepts and measurement. Annu Rev Public Health. 2006;27:167--- 194.

10. Daniels N, Kennedy B, Kawach I. Justice is good for our health. Boston Review 2000 February/March 25(1): 4---19.

11. Wagstaff A, van Doorslaer E. Equity in health care finance and delivery. In: Culyer S, Newhouse J, eds. Handbook of Health Economics. Amsterdam: North Holland; 2000.

12. Sen A. The Idea of Justice. Cambridge, MA: Harvard University Press; 2009.

13. Braveman P, Gruskin S. Poverty, equity, human rights and health. Bull World Health Organ. 2003;81(7):539---545.

14. Braveman P, Gruskin S. Defining equity in health. J Epidemiol Community Health. 2003;57(4):254---258.

15. Braveman P, Starfield B, Geiger HJ. World Health Report 2000: how it removes equity from the agenda for public health monitoring and policy. BMJ. 2001;323(7314):678---681.

16. Culyer AJ. Equity––some theory and its policy implications. J Med Ethics. 2001; 27(4):275---283.

17. Daniels N, Bryant J, Castano RA, et al. Benchmarks of fairness for health care reform: a policy tool for developing countries. Bull World Health Organ. 2000;78(6):740---750.

18. Braveman P, Krieger N, Lynch J. Health inequalities and social inequalities in health. Bull World Health Organ. 2000;78(2):232---235.

19. Rawls J. A Theory of Justice. Cam- bridge: Belknap/Harvard University Press; 1971.

20. Ruger JP. Health and social justice. Lancet. 2004;364(9439):1075---1080.

21. Whitehead M. The concepts and principles of equity and health. Health Promot Int. 1991;6(3):217---228.

22. Voelker R. Decades of work to reduce disparities in health care produce limited success. JAMA. 2008;299(12): 1411---1413.

23. Braveman P, Egerter S. Overcoming Obstacles to Health: Report from the Robert Wood Johnson Foundation to the Commis- sion to Build a Healthier America. Prince- ton, NJ: Robert Wood Johnson Founda- tion; 2008.

24. Singh GK, Kogan MD. Widening socioeconomic disparities in US child- hood mortality, 1969-2000. Am J Public Health. 2007;97(9):1658--- 1665.

25. Singh GK, Siahpush M. Widening socioeconomic inequalities in US life ex- pectancy, 1980-2000. Int J Epidemiol. 2006;35(4):969---979.

26. Fielding J, Kumanyika SK. Recom- mendations for the concepts and form of Healthy People 2020. Am J Prev Med. 2009;37(3):255---257.

27. Beyond Health Care. New Directions to a Healthier America. Recommendations from the Robert Wood Johnson Foundation Commission to Build a Healthier America. Washington, DC: Robert Wood Johnson Foundation Commission to Build a Healthier America; 2009.

28. Jones CP, Hatch A, Troutman A. Fostering a social justice approach to health. In: Braithwaite RL, Taylor SE, Treadwell HM, eds. Health Issues in the Black Community. 3rd ed. Hoboken, NJ: John Wiley & Sons; 2009.

29. Gruskin S, Mills EJ, Tarantola D. History, principles, and practice of health and human rights. Lancet. 2007;370 (9585):449---455.

30. Yamin AE. Shades of dignity: ex- ploring the demands of equality in ap- plying human rights frameworks to health. Health Hum Rights. 2009;11(2): 1---18.

31. Sen A. Development as Freedom. New York: Random House; 1999.

32. UN Committee on Economic, Social and Cultural Rights (CESCR), General comment No. 20: Non-discrimination in economic, social and cultural rights (art. 2, para. 2, of the International Covenant on Economic, Social and Cultural Rights), 2 July 2009, E/C.12/GC/20. Available at: http://www.unhcr.org/refworld/publisher, CESCR,GENERAL,4a60961f2,0.html. Accessed April 7, 2011.

TOWARDS ENVIRONMENTAL JUSTICE AND HEALTH EQUITY

S154 | Environmental Justice | Peer Reviewed | Braveman et al. American Journal of Public Health | Supplement 1, 2011, Vol 101, No. S1

33. Jones CP. Levels of racism: a theo- retic framework and a gardener’s tale. Am J Public Health. 2000;90(8):1212---1215.

34. LaVeist TA, Gaskin DJ, Richard P. The Economic Burden of Health Inequal- ities in the United States. Washington, DC: Joint Center for Political and Economic Studies; 2009.

35. Lerner D, Allaire SH, Reisine ST. Work disability resulting from chronic health conditions. J Occup Environ Med. 2005;47(3):253---264.

36. Vijan S, Hayward RA, Langa KM. The impact of diabetes on workforce participation: results from a national household sample. Health Serv Res. 2004; 39(6p1):1653---1670.

37. International Covenant on Eco- nomic. Social and Cultural Rights (ICESCR), G.A. Res. 2200A (XXI), Art. 12. 1966. Available at http://www2.ohchr. org/english/law/cescr.htm. Accessed April 7, 2011.

38. UN Economic and Social Council. Committee on Economic, Social and Cultural Rights. The Right to the Highest Attainable Standard of Health. General Comment No. 14. (E/C.12/2000/4), 2000.

39. Daniels N. Democratic equality: Rawls’ complex egalitarianism. In: Free- man S, ed. The Cambridge Companion to Rawls. Cambridge, UK: Cambridge Uni- versity Press; 2003:241---276.

40. Sen A. Why health equity? Health Econ. 2002;11(8):659---666.

41. U.N. Economic and Social Council. Committee on Social and Cultural Rights, 43rd Session. The Limburg Principles on the Implementation of the International Covenant on Economic,. 4th Comment (E/CN 17), April 1987.

42. International Commission of Jurists (ICJ). Maastricht Guidelines on Violations of Economic, Social and Cultural Rights, 26 January 1997. Available at: http:// www1.umn.edu/humanrts/instree/ Maastrichtguidelines_.html. Accessed April 7, 2011.

43. US Department of Health and Hu- man Services. Poverty Guidelines, Re- search, and Measurement. Available at http://aspe.hhs.gov/poverty. Accessed September 7, 2010.

44. European Working Conditions Ob- servatory. Income poverty in the Euro- pean Union. Available at http://www.

eurofound.europa.eu/ewco/surveyreports/ EU0703019D/EU0703019D_3.htm. Accessed September 7, 2010.

45. Starfield B. Improving equity in health: a research agenda. Int J Health Serv. 2001;31(3):545---566.

46. Institute of Medicine, Committee on Understanding Premature Birth and Assuring Healthy Outcomes, Board on Health Sciences Policy. Preterm Birth: Causes, Consequences, and Prevention. Washington, DC: The National Acade- mies Press; 2007.

47. Wadhwa PD, Culhane JF, Rauh V, et al. Stress, infection and preterm birth: a biobehavioural perspective. Paediatr Peri- nat Epidemiol. 2001;15(suppl 2):17---29.

48. Dominguez TP, Dunkel-Schetter C, Glynn LM, et al. Racial differences in birth outcomes: the role of general, pregnancy, and racism stress. Health Psychol. 2008; 27(2):194---203.

49. Hobel CJ, Goldstein A, Barrett ES. Psychosocial stress and pregnancy out- come. Clin Obstet Gynecol. 2008;51(2): 333---348.

50. Lu MC, Halfon N. Racial and ethnic disparities in birth outcomes: a life-course perspective. Matern Child Health J. 2003; 7(1):13---30.

51. Commission on Social Determinants of Health. Closing the Gap in a Generation: Health Equity Through Action on the Social Determinants of Health. Final Report of the Commission on Social Determinants of Health. Geneva, Switzerland: World Health Organization; 2008.

52. Wilkinson R, Marmot M, eds. Social Determinants of Health. The Solid Facts. 2nd ed. Geneva, Switzerland: World Health Organization; 2003.

53. Hebert PL, Sisk JE, Howell EA. When does a difference become a dispar- ity? Conceptualizing racial and ethnic disparities in health. Health Aff (Millwood). 2008;27(2):374---382.

54. Centers for Disease Control and Prevention. Breast cancer rates by race and ethnicity. Available at: http://www. cdc.gov/cancer/breast/statistics/race. htm. Accessed November 30, 2009.

55. Centers for Disease Control and Prevention. State-specific trends in U.S. live births to women born outside the 50 states and the District of Columbia–– United States, 1990 and 2000. MMWR

Morb Mortal Wkly Rep. 2002;51(48): 1091---1095.

56. US Census Bureau. The American Community––Blacks: 2004. American Community Survey Reports. Available at: http://www.census.gov/prod/2007 pubs/acs-04.pdf. Accessed December 11, 2009.

57. US Census Bureau. The American Community––Hispanics: 2004. American Community Survey Reports. Available at: http://www.census.gov/prod/2007 pubs/acs-03.pdf. Accessed December 11, 2009.

58. LaVeist TA. Disentangling race and socioeconomic status: a key to understanding health inequalities. J Urban Health. 2005; 82(2, Suppl. 3):iii26---iii34.

59. Henry J. Kaiser Family Foundation. Putting women’s health care disparities on the map: examining racial and ethnic disparities at the state level. June 2009. Available at: http://www.kff.org/ minorityhealth/upload/7886.pdf. Accessed January 11, 2010.

60. Bond Huie SA, Krueger PM, Rogers RG, Hummer RA. Wealth, race, and mor- tality. Soc Sci Q. 2003;84(3):667---684.

61. Braveman PA, Cubbin C, Egerter S, et al. Socioeconomic status in health re- search: one size does not fit all. JAMA. 2005;294(22):2879---2888.

62. Joint Center for Political and Eco- nomic Studies. African Americans in statewide elective office. Available at: http://www.jointcenter.org/index.php/ current_research_and_policy_activities/ political_participation/black_elected_ officials_roster_introduction_and_ overview/african_americans_in_statewide_ elective_office. Accessed November 30, 2009.

63. Laveist TA. Segregation, poverty, and empowerment: health consequences for African Americans. Milbank Q. 1993; 71(1):41---64.

64. Williams DR, Collins C. Racial resi- dential segregation: a fundamental cause of racial disparities in health. Public Health Rep. 2001;116(5):404---416.

65. Spraggins RE. We the people: Women and men in the United States. US Census Bureau. Census 2000 Special Reports. January 2005. Available at: http://www.census.gov/prod/2005 pubs/censr-20.pdf. Accessed November 30, 2009.

66. Bishaw A, Semega J. Income, Earn- ings, and Poverty Data From the 2007 American Community Survey. U.S. Census Bureau, American Community Survey Re- ports. Washington, DC: U.S. Government Printing Office; 2008.

67. Center for American Women and Politics. Rutgers University. Women in elective office 2009. Fact sheet. Available at: http://www.cawp.rutgers.edu/fast_ facts/levels_of_office/documents/elective. pdf. Accessed November 30, 2009.

68. Agency for Healthcare Research and Quality. National Healthcare Disparities Reports. Data Tables Appendix. Available at: http://www.ahrq.gov/qual/nhdr09/ Chap4c.htm#women. Accessed Septem- ber 7, 2010.

69. Braveman PA, Egerter SA, Cubbin C, Marchi KS. An approach to studying social disparities in health and health care. Am J Public Health. 2004;94(12): 2139---2148.

70. Harper S, Lynch J. Methods for Measuring Cancer Disparities: Using Data Relevant to Healthy People 2010 Cancer-Related Objectives. Bethesda, MD: National Cancer Institute; 2005.

71. Braveman P. Monitoring equity in health and health care: a conceptual framework. J Health Popul Nutr 2003; 21(3):181---192.

72. Mackenbach JP, Kunst AE, Cavelaars AE, et al. Socioeconomic inequalities in morbidity and mortality in western Europe. The EU Working Group on Socioeconomic Inequalities in Health. Lancet. 1997;349(9066):1655---1659.

73. Wagstaff A, Van Doorslaer E. Mea- suring inequalities in health in the pres- ence of multiple-category morbidity indicators. Health Econ. 1994;3(4): 281---289.

74. National Association of City and County Health Officials. Health equity and social justice. Available at: http:// www.naccho.org/topics/justice. Accessed December 10, 2009.

75. Prevention Institute and Health Policy Institute. Reducing inequities in health and safety through prevention. January 23, 2009. Available at: http:// www.preventioninstitute.org/documents/ HealthEquityMemo_012309.pdf. Ac- cessed December 10, 2009.

TOWARDS ENVIRONMENTAL JUSTICE AND HEALTH EQUITY

Supplement 1, 2011, Vol 101, No. S1 | American Journal of Public Health Braveman et al. | Peer Reviewed | Environmental Justice | S155

Copyright of American Journal of Public Health is the property of American Public Health Association and its

content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's

express written permission. However, users may print, download, or email articles for individual use.