Health equity
Health equity arises from access to the social determinants of health, specifically from wealth, power and prestige.[1] Individuals who have consistently been deprived of these three determinants are significantly disadvantaged from health inequities, and face worse health outcomes than those who are able to access certain resources.[2][1] It is not equity to simply provide every individual with the same resources; that would be equality. In order to achieve health equity, resources must be allocated based on an individual need-based principle.[1]
According to the World Health Organization, "Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity".[3] The quality of health and how health is distributed among economic and social status in a society can provide insight into the level of development within that society.[4] Health is a basic human right and human need, and all human rights are interconnected. Thus, health must be discussed along with all other basic human rights.[1]
Health equity is defined by the CDC as "the state in which everyone has a fair and just opportunity to attain their highest level of health".[5] It is closely associated with the social justice movement, with good health considered a fundamental human right. These inequities may include differences in the "presence of disease, health outcomes, or access to health care"[6]: 3 between populations with a different race, ethnicity, gender, sexual orientation, disability, or socioeconomic status.[7][8]
Health inequity differs from health inequality in that the latter term is used in a number of countries to refer to those instances whereby the health of two demographic groups (not necessarily ethnic or racial groups) differs despite similar access to health care services. It can be further described as differences in health that are avoidable, unfair, and unjust, and cannot be explained by natural causes, such as biology, or differences in choice.[9] Thus, if one population dies younger than another because of genetic differences, which is a non-remediable/controllable factor, the situation would be classified as a health inequality. Conversely, if a population has a lower life expectancy due to lack of access to medications, the situation would be classified as a health inequity.[10] These inequities may include differences in the "presence of disease, health outcomes, or access to health care". Although, it is important to recognize the difference in health equity and equality, as having equality in health is essential to begin achieving health equity.[1] The importance of equitable access to healthcare has been cited as crucial to achieving many of the Millennium Development Goals.[11]
Health inequality and environmental influence[edit]
Minority populations have increased exposure to environmental hazards that include lack of neighborhood resources, structural and community factors as well as residential segregation that result in a cycle of disease and stress.[130] The environment that surrounds us can influence individual behaviors and lead to poor health choices and therefore outcomes.[131] Minority neighborhoods have been continuously noted to have more fast food chains and fewer grocery stores than predominantly white neighborhoods.[131] These food deserts affect a family's ability to have easy access to nutritious food for their children. This lack of nutritious food extends beyond the household into the schools that have a variety of vending machines and deliver over processed foods.[131] These environmental condition have social ramifications and in the first time in US history is it projected that the current generation will live shorter lives than their predecessors will.[131]
In addition, minority neighborhoods have various health hazards that result from living close to highways and toxic waste factories or general dilapidated structures and streets.[131] These environmental conditions create varying degrees of health risk from noise pollution, to carcinogenic toxic exposures from asbestos and radon that result in increase chronic disease, morbidity, and mortality.[132] The quality of residential environment such as damaged housing has been shown to increase the risk of adverse birth outcomes, which is reflective of a communities health. This occurs through exposure to lead in paint and lead contaminated soil as well as indoor air pollutants such as second-hand smoke and fine particulate matter.[133][134] Housing conditions can create varying degrees of health risk that lead to complications of birth and long-term consequences in the aging population.[134] In addition, occupational hazards can add to the detrimental effects of poor housing conditions. It has been reported that a greater number of minorities work in jobs that have higher rates of exposure to toxic chemical, dust and fumes.[135] One example of this is the environmental hazards that poor Latino farmworkers face in the United States. This group is exposed to high levels of particulate matter and pesticides on the job, which have contributed to increased cancer rates, lung conditions, and birth defects in their communities.[136]
Racial segregation is another environmental factor that occurs through the discriminatory action of those organizations and working individuals within the real estate industry, whether in the housing markets or rentals. Even though residential segregation is noted in all minority groups, Black people tend to be segregated regardless of income level when compared to Latinos and Asians.[137] Thus, segregation results in minorities clustering in poor neighborhoods that have limited employment, medical care, and educational resources, which is associated with high rates of criminal behavior.[138][139] In addition, segregation affects the health of individual residents because the environment is not conducive to physical exercise due to unsafe neighborhoods that lack recreational facilities and have nonexistent park space.[138] Racial and ethnic discrimination adds an additional element to the environment that individuals have to interact with daily.[140] Individuals that reported discrimination have been shown to have an increase risk of hypertension in addition to other physiological stress related affects.[141] The high magnitude of environmental, structural, socioeconomic stressors leads to further compromise on the psychological and physical being, which leads to poor health and disease.[130]
Individuals living in rural areas, especially poor rural areas, have access to fewer health care resources. Although 20 percent of the U.S. population lives in rural areas, only 9 percent of physicians practice in rural settings. Individuals in rural areas typically must travel longer distances for care, experience long waiting times at clinics, or are unable to obtain the necessary health care they need in a timely manner. Rural areas characterized by a largely Hispanic population average 5.3 physicians per 10,000 residents compared with 8.7 physicians per 10,000 residents in nonrural areas. Financial barriers to access, including lack of health insurance, are also common among the urban poor.[142]
Health inequalities[edit]
Health inequality is the term used in a number of countries to refer to those instances whereby the health of two demographic groups (not necessarily ethnic or racial groups) differs despite comparative access to health care services. Such examples include higher rates of morbidity and mortality for those in lower occupational classes than those in higher occupational classes, and the increased likelihood of those from ethnic minorities being diagnosed with a mental health disorder. In Canada, the issue was brought to public attention by the LaLonde report.
In UK, the Black Report was produced in 1980 to highlight inequalities. On 11 February 2010, Sir Michael Marmot, an epidemiologist at University College London, published the Fair Society, Healthy Lives report on the relationship between health and poverty. Marmot described his findings as illustrating a "social gradient in health": the life expectancy for the poorest is seven years shorter than for the most wealthy, and the poor are more likely to have a disability. In its report on this study, The Economist argued that the material causes of this contextual health inequality include unhealthful lifestyles – smoking remains more common, and obesity is increasing fastest, amongst the poor in Britain.[201]
In June 2018, the European Commission launched the Joint Action Health Equity in Europe.[202] Forty-nine participants from 25 European Union Member States will work together to address health inequalities and the underlying social determinants of health across Europe. Under the coordination of the Italian Institute of Public Health, the Joint Action aims to achieve greater equity in health in Europe across all social groups while reducing the inter-country heterogeneity in tackling health inequalities.
Bias in research[edit]
Research to identify health inequities, how they arise and what can be done to address them is essential to securing health equity. However, the same exclusionary social structures that contribute to health inequities in society also influence and are reproduced by researchers and public health institutions.[203] In other words, medicine and public health organizations have evolved to better meet the needs of some groups more than others. While there are many examples of bias in medical and public health research, some general categories of exclusionary research practices include:[204] 1) Structural invisibility – approaches to collection, analysis or publication of data which hide the potential contribution of social factors to the distribution of health risks or outcomes. For example, limitations in public health surveys in the United States to collect data on race, ethnicity, and nativity; (2) Institutionalized exclusion – codification of exclusionary social structures in research practices, instruments, and scientific models resulting in an inherent bias in favor of the normative group. For example, the definition of a human as an 80 kg man in toxicology; (3) Unexamined assumptions – cultural norms and unconscious bias that can impact all aspects of research. In other words, assuming that the researchers' perspective and understanding is objective and universally shared. For example, the lack of conceptual equivalence across multi-lingual survey instruments.[205][206]
Health disparity and genomics[edit]
Genomics applications continue to increase in clinical/medical applications. Historically, results from studies do not include underrepresented communities and races.[207] The question of who benefits from publicly funded genomics is an important public health consideration, and attention will be needed to ensure that implementation of genomic medicine does not further entrench social‐equity concerns.[208] Currently the National Human Genome Research Institute counts with a Genomics and Health Disparities Interest Group to tackle the issues of accessibility and application of genomic medicine to communities not normally represented. The Director of the Health Disparities Group, Vence L. Bonham Jr., leads a team that seeks to qualify and better understand the disparities and reduce the gap in access to genetic counseling, inclusion of minority communities in original research, and access to genetic information to improve health.[209]
There is some movement toward progress, though. Sickle cell disease, which disproportionately impacts Black people where every 1 of 365 births[210] has the condition, is treatable with gene therapy. In December 2023, the United States' Food and Drug Administration (FDA) approved two gene therapy treatments[211] that use gene editing machinery known as CRISPR/Cas9 to alleviate the sickling of the red blood cells. This will greatly improve the livelihoods of millions, but especially people of color who are much more at risk for this condition.