Health Disparities and Health Equity: The Issue Is Justice (2011) PDF

TOWARDS ENVIRONMENTAL JUSTICE AND HEALTH EQUITY Health Disparities and Health Equity: The Issue Is Justice Eliminating health dis- Paula A. Braveman, MD, MPH, Shiriki Kumanyika, PhD, MPH, Jonathan Fielding, MD, MPH, MA, MBA, parities is a Healthy Peo- Thomas LaVeist,...

TOWARDS ENVIRONMENTAL JUSTICE AND HEALTH EQUITY Health Disparities and Health Equity: The Issue Is Justice Eliminating health dis- Paula A. Braveman, MD, MPH, Shiriki Kumanyika, PhD, MPH, Jonathan Fielding, MD, MPH, MA, MBA, parities is a Healthy Peo- Thomas LaVeist, PhD, Luisa N. Borrell, DDS, PhD, Ron Manderscheid, PhD, ple goal. Given the diverse and Adewale Troutman, MD, MPH, MA and sometimes broad defi- nitions of health disparities commonly used, a sub- ONE OF 2 OVERARCHING cultural, and technical perspec- wording. Clarifying these concepts committee convened by the goals of Healthy People 20101 was tives may generate different defi- will enable medical and public Secretary’s Advisory Com- ‘‘to eliminate health disparities nitions of health disparities or in- health practitioners and leaders to mittee for Healthy People among different segments of the equalities (the most comparable be more effective in reducing dis- 2020 proposed an opera- population.’’ A similar goal to term outside the United States).9---21 parities in medical care and in tional definition for use in ‘‘achieve health equity and elimi- For example, in the United King- advocating for social policies (e.g., developing objectives and nate health disparities’’ was pro- dom, Whitehead defined health in child care, education, housing, targets, determining re- posed by the Health and Human inequalities as differences that are labor, and urban planning) that source allocation priorities, and assessing progress. Services Secretary’s Advisory unnecessary, avoidable, and un- can have major impacts on popu- Based on that subcom- Committee (SAC) for Healthy Peo- fair.21 This definition is widely lation health.27 mittee’s work, we propose ple 2020.2 Healthy People 2010 used internationally, where that health disparities are noted that health disparities ‘‘in- ‘‘health inequalities’’ are assumed UNDERLYING VALUES AND systematic, plausibly avoid- clude differences that occur by to be socioeconomic differences PRINCIPLES able health differences ad- gender, race or ethnicity, educa- unless otherwise specified; in the versely affecting socially tion or income, disability, living in United States, however, ‘‘health The concepts of health dispar- disadvantaged groups; they rural localities, or sexual orienta- disparities’’ more often refer to ities and health equity are rooted may reflect social disad- tion.’’1 However, the rationale for racial or ethnic differences. in deeply held American social vantage, but causality need identifying disparities in relation Effective public policies require values and pragmatic consider- not be established. This def- to these particular population clear and contextually relevant ations, as well as in internationally inition, grounded in ethical and human rights princi- groups was not articulated. The operational definitions to support recognized ethical and human ples, focuses on the subset National Institutes of Health de- the development of objectives and rights principles.9 Drawing on of health differences re- fined health disparities as ‘‘differ- specific targets, determine priori- ethical and human rights concepts, flecting social injustice, ences in the incidence, prevalence, ties for use of limited resources, key principles underlying the distinguishing health dis- mortality, and burden of diseases and assess progress. The need for concepts of health disparities and parities from other health and other adverse health condi- clear definitions is particularly health equity include the following: differences also warranting tions that exist among specific compelling given the lack of prog- concerted attention, and population groups in the United ress toward reducing racial/ethnic All people should be valued from health differences in States’’3,4; several other federal and socioeconomic disparities in equally. This concept was artic- general. agencies have similarly broad medical care22 and health.23---25 ulated by Jones et al.28 as foun- We explain the definition, definitions.5 The lack of explicit Recognizing the practical implica- dational to the concept of eq- its underlying concepts, the challenges it addresses, and criteria for identifying disparities tions of lack of clarity on this uity. Equal worth of all human the rationale for applying it to in Healthy People 20101 and the critical issue, the SAC convened beings is at the core of the United States public health relatively nonspecific definitions a subcommittee to define ‘‘health human rights principle that all policy. (Am J Public Health. of disparities used by federal disparity’’ and ‘‘health equity’’ for human beings equally possess 2011;101:S149–S155. doi:10. agencies3,4 leave considerable use in Healthy People 2020.2 The certain rights.29,30 2105/AJPH.2010.300062) room for ambiguity as to what subcommittee members, including Health has a particular value for other groups might also be rele- both SAC members and external individuals because it is essential vant. experts, wrote this paper to elab- to an individual’s well-being Furthermore, there has been orate on the definitions and ex- and ability to participate fully in controversy as to whether defini- plain their rationale.2,26 These defi- the workforce and a democratic tions of health disparities should nitions (see the box on the next society. Ill health means potential imply injustice or simply reflect page) and the rationale presented suffering, disability, and/or loss differences in health outcomes are substantively consistent with of life, threatens one’s ability to that might apply to any United those adopted by the SAC and re- earn a living, and is an obstacle States population segment.6---8 Dif- cently published in Healthy People to fully expressing one’s views ferent ethical, philosophical, legal, 2020,2 but reflect some changes in and engaging in the political Supplement 1, 2011, Vol 101, No. S1 | American Journal of Public Health Braveman et al. | Peer Reviewed | Environmental Justice | S149  TOWARDS ENVIRONMENTAL JUSTICE AND HEALTH EQUITY process. The Nobel Laureate economist Amartya Sen31 Health Disparities and Health Equity viewed health as a fundamental Health disparities are health differences that adversely affect socially disadvantaged groups. capability required to function Health disparities are systematic, plausibly avoidable health differences according to race/ethnicity, in society; similarly, ill health skin color, religion, or nationality; socioeconomic resources or position (reflected by, e.g., income, can be a barrier to fully re- wealth, education, or occupation); gender, sexual orientation, gender identity; age, geography, alizing one’s human rights. disability, illness, political or other affiliation; or other characteristics associated with discrimination or marginalization. These categories reflect social advantage or disadvantage when they determine Because ill health can be an an individual’s or group’s position in a social hierarchy (see the box on the next page). obstacle to overcoming disad- Health disparities do not refer generically to all health differences, or even to all health differences vantages, health disparities, warranting focused attention. They are a specific subset of health differences of particular relevance which further disadvantage so- to social justice because they may arise from intentional or unintentional discrimination or cially disadvantaged groups, marginalization and, in any case, are likely to reinforce social disadvantage and vulnerability. seem particularly unfair. Disparities in health and its determinants are the metric for assessing health equity, the principle Nondiscrimination and equality. underlying a commitment to reducing disparities in health and its determinants; health equity is Every person should be able to social justice in health. achieve his/her optimal health status, without distinction based on race or ethnic group, skin obligation to maximize the well- governments to respect, protect, housing, environmental protec- color, religion, language, or na- being of those worst off. An fulfill, and promote all human tion, and other factors that are tionality; socioeconomic re- aversion to discrimination is rights of all persons, including also crucial to health and well- sources or position; gender, also firmly rooted in United the ‘‘right to the highest attain- being.38 sexual orientation, or gender States policies, as exemplified by able standard of health’’ and the Health differences adversely af- identity; age; physical, mental, the Civil Rights Act of 1964 right to a standard of living fecting socially disadvantaged or emotional disability or ill- prohibiting discrimination on adequate for health and well- groups are particularly unac- ness; geography; political or the basis of race, color, or na- being. Governments must dem- ceptable because ill health can be other affiliation; or other char- tional origin; the 1954 Brown onstrate good faith in progres- an obstacle to overcoming social acteristics that have been linked vs. Board of Education decision sively removing obstacles to re- disadvantage. This consideration historically to discrimination or desegregating schools; the Hill alizing these rights.29 The United resonates with common sense marginalization (exclusion from Burton Act of 1946 prohibiting States signed but did not ratify notions of fairness, as well as social, economic, or political hospitals receiving federal funds the International Covenant on with ethical concepts of justice, opportunities). The groups rep- from discriminating on the basis Economic, Social, and Cultural notably, the concept that need resented by these characteristics of race, color, or creed; and the Rights, which articulated the should be a key determinant of substantively agree with those Americans with Disabilities Acts right to health. Signing a treaty, resource allocation for health, specified by the United Nations of 1990 and 2008 prohibiting however, is considered an en- and Rawls’ notion of the obli- Committee on Economic, Social discrimination on the basis of dorsement of its principles and gation to maximize the well- and Cultural Rights as vulnera- physical or mental disability. reflects acceptance of a good being of those worst off.39 ble groups whose rights are at Health is also of special impor- faith commitment to honor its Sen noted as a ‘‘particularly se- particular risk of being unreal- tance for society because a na- contents. The ‘‘right to health’’ rious... injustice... the lack ized, due to historic discrimina- tion’s prosperity depends on the (i.e., ‘‘the right of everyone to the of opportunity that some may tion.32 This directly reflects the entire population’s health. enjoyment of the highest attain- have to achieve good health human rights principles of Healthy workers are more pro- able standard of physical and because of inadequate social nondiscrimination and equality; ductive and generate lower an- mental health’’37) is ‘‘not to be arrangements....’’40 Sen argued nondiscrimination includes nual medical care costs.34---36 understood as a right to be heal- that health is a prerequisite for not only intentional but also A healthier population has thy,’’ because too many factors the capability to function nor- unintentional or de facto more workers available for the beyond states’ control influence mally in society.31 It is therefore discrimination, meaning dis- workforce. Health can facilitate health. Rather, it is ‘‘the right to particularly unjust that those criminatory treatment embed- political participation, which a system of health protection who are socially disadvantaged ded in structures and institu- is essential for democracy. which provides equality of op- should also experience addi- tions, regardless of whether Rights to health and to a standard portunity to enjoy the highest tional obstacles to opportunity there is conscious intent to dis- of living adequate for health. In- attainable level of health.’’ It in- based on having worse health. criminate.32,33 The late philos- ternational human rights agree- cludes the right to equal access to Ratifying human rights agree- opher John Rawls19 advanced ments, to which virtually all cost-effective medical care as ments obliges governments to the concept of a society’s ethical countries are signatories, obligate well as to child care, education, direct special effort toward S150 | Environmental Justice | Peer Reviewed | Braveman et al. American Journal of Public Health | Supplement 1, 2011, Vol 101, No. S1  TOWARDS ENVIRONMENTAL JUSTICE AND HEALTH EQUITY equalizing the rights of vulner- those who were worse off to although a causal link need not be thereby making it potentially more able groups facing more obsta- start, within an overall strategy demonstrated. Differences among difficult to overcome social disad- cles to realizing their rights. A to improve everyone’s health. groups in their levels of social vantage. This reinforcement or nonexhaustive list of vulnerable Closing health gaps by worsen- advantage or disadvantage, which compounding of social disadvan- groups is specified in human ing advantaged groups’ health is can be thought of as where tage is what makes health dispar- rights documents on non- not a way to achieve equity. groups rank in social hierarchies, ities relevant to social justice even discrimination and equal- Reductions in health disparities are indicated by measures when knowledge of their causa- ity.32,37,41,42 (by improving the health of the reflecting the extent of wealth, tion is lacking. It is important to The resources needed to be socially disadvantaged) are the political or economic influence, define health disparities without healthy (i.e., the determinants of metric by which progress to- prestige, respect, or social accep- requiring proof of causality, be- health, including living and ward health equity is measured. tance of different population cause there are important health working conditions necessary for groups. disparities for which the causes health, as well as medical care) have not been established, but should be distributed fairly. To HEALTH DISPARITIES: Systematic But Not which deserve high priority based do so requires considering need DEFINITION AND Necessarily Causal Links With on social justice concerns. For (along with capacity to benefit16 RATIONALE Social Disadvantage example, the large Black---White and efficiency17) rather than As noted by Starfield,45 health disparity in low birth weight ability to pay or influence in We briefly define health dis- disparities are systematic, that is, and premature birth strongly pre- society.17 This principle, along parities and health equity (see the not isolated or exceptional find- dicts disparities in infant mortality with principles cited previously, box on the previous page), elabo- ings. Health disparities are sys- and child development, and reflects the ethical notion of rating further and explaining in tematically linked with social dis- likely in adult chronic disease.46 distributive justice (a just distri- this section. We also discuss social advantage, and may reflect social Although the causes of racial bution of resources needed for disadvantage, a key concept for disadvantage, although a causal disparity in birth outcomes are health) and the human rights understanding disparities and eq- link does not need to be demon- not established,46 credible scientific principles of nondiscrimination uity (see the box on this page). strated. Whether or not a causal sources have identified biologi- and equality, as well as the Health disparities are systematic, link exists, health disparities ad- cal mechanisms that plausibly right to a standard of living ade- plausibly avoidable health differ- versely affect groups who are al- contribute to the disparities,46---50 quate for health. Investments ences adversely affecting socially ready disadvantaged socially, put- which reflect phenomena shaped in medical care intended to disadvantaged groups. They ting them at further disadvantage by social contexts and thus are, at reduce disparities must be may reflect social disadvantage, with respect to their health, least theoretically, avoidable. weighed against other poten- tially more effective invest- ments that address disparities in other health determinants.38 Social Disadvantage Health equity is the value under- lying a commitment to reduce and Health disparities and health equity cannot be defined without defining social disadvantage. ultimately eliminate health dis- 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. parities. It is explicitly men- It means restricted ability to participate fully in society and enjoy the benefits of progress. Social tioned in the Healthy People disadvantage is reflected, for example, by low levels of wealth, income, education, or occupational 2020 2 objectives. Health eq- rank, or by less representation at high levels of political office. Criteria for social disadvantage can uity means social justice with be absolute (e.g., the federal poverty threshold in the United States is based on an estimate of the respect to health and reflects the income needed to obtain a defined set of basic necessities for a family of a given size)43 or relative ethical and human rights con- (e.g., poverty levels in a number of European countries are defined in relation to the median cerns articulated previously. income, e.g., less than 50% of the median income).44 Health equity means striving to Not all members of a disadvantaged group will necessarily be (uniformly) disadvantaged, and not all equalize opportunities to be socially disadvantaged groups will necessarily manifest measurable adverse health consequences. healthy. In accord with the The extent (whether in a single or multiple domains), depth (severity), and duration (e.g., across other ethical principles of be- multiple generations) of disadvantage matter. Social disadvantage is different from unavoidable physical disadvantage due to, for example, an unavoidable physical disability. However, when neficence (doing good) and disabled persons are put at an unnecessary disadvantage in society due to lack of feasible nonmalfeasance (doing no supports (e.g., accessible public buildings and transportation) or to discrimination against them in harm), equity requires con- hiring for work that they could perform, this would constitute social disadvantage, certed effort to achieve more reflecting discriminatory treatment, whether intentional or unintentional. rapid improvements among Supplement 1, 2011, Vol 101, No. S1 | American Journal of Public Health Braveman et al. | Peer Reviewed | Environmental Justice | S151  TOWARDS ENVIRONMENTAL JUSTICE AND HEALTH EQUITY Plausibly Avoidable and efficiently to reduce important Disadvantaged Groups Are issue is whether the group has been Differences in Health Given disparities. Not Necessarily Uniformly on the whole more disadvantaged Sufficient Political Will Disadvantaged than Whites. Ample evidence has It must be plausible, but not Worse Health Among Socially Internationally recognized hu- documented a longstanding pattern necessarily proven, that policies Disadvantaged Groups man rights documents provide of less wealth,60,61 lower incomes, could reduce the disparities, in- Socially disadvantaged groups guidance on which groups are lower educational attainment, and cluding not only policies affecting are defined a priori, according to disadvantaged. Although health under-representation in positions medical care but also social poli- criteria consistent with human disparities are systematic, a so- of high occupational rank56 and cies addressing important non- rights principles regarding non- cially disadvantaged group will financial and political power62 medical determinants of health discrimination and equality. not necessarily fare worse on all among Blacks as a group com- and health disparities, such as a Health disparities and equity health indicators, and might fare pared with Whites. Despite an end should be central considerations better on some. For example, non- to legal racial segregation decades decent standard of living; a level of for public policy relevant to Hispanic European American or ago, racial residential segregation schooling permitting full social health, but they are not the only White (hereafter ‘‘White’’) women persists and with it, de facto edu- participation, including participa- considerations. Other legitimate over age 40 have higher incidence cational segregation, condemning tion in the workforce and political considerations include the mag- of breast cancer than non-His- many Black children to poor activities; health-promoting living nitude of impact and proportion quality schools. This reduces their and working conditions, includ- panic African American or Black of the population affected, as chances of obtaining good jobs ing both social and physical envi- (hereafter ‘‘Black’’) women,54 and well as efficiency in the use of with adequate income as adults, ronments; and respect and social babies born to Hispanic immigrant resources. If a more socially perpetuating social disadvantage acceptance.23,51 This criterion women often have more favorable advantaged group happens to across generations.63,64 addresses the issue of avoidability, birth weights than those born to fare worse on a particular health Similarly, although many which is central to Whitehead’s non-Hispanic Whites.55 Neither of indicator, this may be a very im- United States women are affluent these differences––although both definition of health inequalities; it portant issue that public health and some now hold high profes- deserve public health attention–– strives for more specificity about or other sectors should energeti- sional and political offices, as would be a health disparity by the avoidability and to clarify the bur- cally address; but it is not part of a group, they are more likely proposed definition. Regardless den of proof regarding causality.21 a ‘‘health disparities’’ agenda, than men to be poor,65 to earn of this type of exception in relation Avoidability can be highly sub- which focuses on improving the less at a given educational level,66 to a health outcome, Whites as jective. For example, one person health of socially disadvantaged and to be underrepresented in may believe that ill health caused groups. a group are more socially advan- high political office.67 Human by poverty is avoidable; another, taged than Blacks and Hispanics, rights documents on nondiscrim- however, may believe that both The Need to Reduce as data on income, wealth, educa- ination explicitly name women as poverty and ill health among the Disparities in the tion, occupations, and political a vulnerable group warranting poor are inevitable; hence, these Determinants of Health office have documented.56---58 special protection from discrimi- disparities are unavoidable. Ac- Health determinants include Furthermore, on most health indi- nation. Patterns suggesting clini- cording to the proposed definition, not only medical care but also the cators, including breast cancer mor- cally unjustified underreceipt of the criterion is whether the given quality of the social and physical tality, White women are healthier certain cardiac treatments by condition is theoretically avoidable, conditions in which people live, than Black women.59 Similarly, women compared with men68 based on current knowledge of work, learn, and play.23,51,52 higher rates of a preventable would reflect a gender disparity plausible causal pathways and bi- Evidence of disparities in health illness in 1 of 2 affluent geographic in a determinant of health ological mechanisms, and assuming determinants is thus relevant to regions would warrant public (medical care, in this instance). the existence of sufficient political assessing disparities in health. health action, but not as a health Shorter life expectancy among will. The more solid the knowl- Society will generally be more disparities concern. men in general, if likely avoid- edge, the more reasonable and motivated to address health dif- The fact that not all members able, would clearly be an issue of politically viable it will be to invest ferences that appear to result of a disadvantaged group (e.g., public health importance based resources in interventions; feasi- from modifiable circumstances Blacks) appear to be severely dis- on the magnitude of potential bility, costs, and potentially harm- over which individuals may have advantaged (e.g., we have a Black population impact. However, ful unintended consequences little control21,53; for example, United States President, and men as a group have more must be considered. Without firm the quality of local schools, ex- some Blacks are highly educated, wealth, influence, and prestige, so knowledge to guide specific inter- posure to pollution or crime, in high professional positions, this difference would not be ventions, pursuing health equity or absence of stores selling nu- and/or wealthy) does not contra- a social injustice and, therefore, would require supporting research tritious food in one’s neighbor- dict considering that group as not a health disparity or equity on how to intervene effectively hood. generally disadvantaged. The issue. S152 | Environmental Justice | Peer Reviewed | Braveman et al. American Journal of Public Health | Supplement 1, 2011, Vol 101, No. S1  TOWARDS ENVIRONMENTAL JUSTICE AND HEALTH EQUITY Health Disparities as the Health inequity, however, is a Limitations advantage. The causes need not be Metric to Assess Progress forceful term tending to imply These definitions do not pro- known definitively, if it is biologi- Toward Health Equity a strong judgment about causality, vide numerical cutoffs for deter- cally plausible that the difference The stated criteria permit the which may be difficult to support in mining disadvantage. Nor do they could be reduced by policies. assessment of measurable prog- many cases that nevertheless de- remove completely the need to These definitions also ground the ress toward greater health equity. serve attention as health disparities exercise judgment based on values concepts of health disparities and Systematic associations with social (i.e., health differences adversely that are likely to vary across in- health equity in internationally disadvantage can be identified by affecting socially disadvantaged dividuals and societies. It is recognized principles from the observing a repeated pattern of groups) regardless of their causa- difficult to imagine reasonable fields of ethics and human rights, correlations between measures of tion. As with health equity, mea- definitions of these concepts, giving them universality and du- social disadvantage and a health suring health inequity relies on however, that would provide rigid rability. Although human rights outcome. Social advantage and health disparities as the metric. cutoffs, would completely pre- are often honored more in the disadvantage can be measured by clude the exercise of judgment, breach than in the observance, comparing populations on factors Health Disparity: Not Just and would leave no room for they are a powerful resource in such as levels of wealth, income, a Health Difference contention. The proposed defini- that they represent a global con- educational attainment, or occu- Interpreting the term ‘‘health tions do not clarify whether the sensus on values. This consensus pational rank, for example (see the disparities’’ as any health differ- reference group for making eq- can be an important point of ref- box on page S151). Demonstrating ences among any population erence in national and local de- uity/disparities comparisons that a given disparity is plausibly group, as has been done by some bates on policies and practice in should be the most advantaged federal agencies, encompasses the the United States. It would be avoidable and can be reduced by group in one’s country or in the entire domain of epidemiology, naı̈ve to think that achieving con- policies requires being able to de- world; using one’s country as the which is the study of the distribu- sensus on a definition would ob- scribe, at least in general terms, 1 reference point may ignore the tion of diseases and risk factors viate the need for constant vigi- or more potential causal pathways better health achieved by advan- across different populations. We lance to ensure that the agenda for that are consistent with current taged populations in other parts of have argued that the term health research and action on health dis- scientific knowledge; it does not the world. disparities should be used advis- parities remains on track and true require definitively establishing edly, in the spirit of the movement to the essence of the definition; either the causation of the dispar- Challenges Addressed for social justice from which the however, having a clear definition ity or proving the effectiveness of The definitions address major term emerged, to refer to a partic- is crucial. existing interventions to reduce challenges, such as identifying the ular subset of differences in health it. Guidelines for measuring health social groups to be compared and that meet well-specified criteria The Issue is Justice disparities are available.9,69---73 specifying the general criteria for of specific relevance to social jus- Could this approach––putting Increasingly, the term ‘‘health appropriate reference groups for tice. The definitions proposed here health disparities within the inequity’’21,74,75––the opposite of these comparisons.18 These chal- were designed to clarify the con- broader context of ethics and hu- health equity––is being used in- lenges have arisen when consid- cepts of health disparities and man rights––jeopardize the limited stead of ‘‘health disparity’’ to cap- health equity in ways that could ering health disparity or equity resources allocated to specifically ture explicitly the moral dimension stand up to rigorous conceptual issues, with serious implications address racial/ethnic disparities, and differentiate health differences scrutiny as a basis for guiding for resource allocation. These by spreading these resources more thought to reflect injustice from policy and practice and ensuring definitions remove the need to thinly among other disadvantaged health differences in general. Ex- accountability, which requires establish the causality and avoid- groups? Would broadening the amples of health differences that clear criteria for measure- ability of each health difference for definition make the concept too would not be considered health ment.9,69,70 To achieve the de- it to qualify as a health disparity abstract and therefore less com- disparities according to our defi- sired rigor, the full versions of the worthy of special attention. To ad- pelling to the public and policy- nitions (see the box on page S150) proposed definitions are complex dress the difficult issue of causality, makers? We concluded that the include: elderly adults generally and technical and will not be suit- our definitions acknowledge that struggle for racial justice, in which having worse health than noneld- able for all audiences; for many a health disparity may or may not efforts to eliminate racial/ethnic erly adults; skiers being at higher audiences, it may be most appro- arise from social disadvantage, but disparities in health are crucial, risk of long-bone fractures than priate to define health disparities it must adversely affect members of has far more to gain than to lose nonskiers; and men not having simply as worse health among socially disadvantaged groups; this from making these principles ex- obstetric problems, whereas socially disadvantaged groups can be assessed using epidemiologic plicit. The relevant ethical and women do. Both ‘‘health disparity’’ and then elaborate as necessary, data revealing repeated and perva- human rights principles support and ‘‘health inequity’’ have their drawing on the more comprehen- sive associations between health prioritizing attention to those fac- place in the public health lexicon. sive form of the definitions. indicators and measures of social ing the greatest obstacles, and Supplement 1, 2011, Vol 101, No. S1 | American Journal of Public Health Braveman et al. | Peer Reviewed | Environmental Justice | S153  TOWARDS ENVIRONMENTAL JUSTICE AND HEALTH EQUITY ample evidence has documented 3333 California St., Suite 365, San Francisco, 2020, November 2010. Available at: 19. Rawls J. A Theory of Justice. Cam- CA 94118 (e-mail: [email protected]). http://www.healthypeople.gov/2020/ bridge: Belknap/Harvard University the multiple and often crushing Reprints can be ordered at http://www.ajph. about/disparitiesAbout.aspx. Accessed Press; 1971. obstacles faced by members of org by clicking the ‘‘Reprints/Eprints’’ link. April 8, 2011. 20. Ruger JP. Health and social justice. disadvantaged racial/ethnic This article was accepted November 1, 3. National Institute of Arthritis and Lancet. 2004;364(9439):1075---1080. 2010. groups in the United States, in Musculoskeletal and Skin Diseases. Strate- 21. Whitehead M. The concepts and gic plan for reducing health disparities. some cases for centuries. These principles of equity and health. Health Contributors Available at: http://www.niams.nih.gov/ principles can protect initiatives Promot Int. 1991;6(3):217---228. All the authors participated conceptually About_Us/Mission_and_Purpose/strat_ to address racial/ethnic as well as plan_hd.asp. Accessed September 7, 2010. 22. Voelker R. Decades of work to in developing the recommendations to reduce disparities in health care produce other disparities in health from the Secretary’s Advisory Committee 4. National Cancer Institute. Health limited success. JAMA. 2008;299(12): (SAC) on Healthy People 2020, which disparities defined. Available at: http:// a range of potential challenges were the starting point for this article, and 1411---1413. crchd.cancer.gov/disparities/defined.html. that constitute real threats. all authors contributed ideas, reviewed Accessed September 7, 2010. 23. Braveman P, Egerter S. Overcoming Previous official approaches to drafts, and made comments that shaped Obstacles to Health: Report from the Robert 5. Carter-Pokras O. What is a ‘‘health this article in important ways. P. A. Wood Johnson Foundation to the Commis- defining health disparities in the Braveman conceived the initial idea for disparity’’? Public Health Rep. 2002;117: sion to Build a Healthier America. Prince- United States have avoided being 426---434. the article, wrote initial drafts, and wrote ton, NJ: Robert Wood Johnson Founda- explicit about values and princi- most revisions for coauthors’ review, 6. Jones CM. The moral problem of tion; 2008. based on their comments. S. Kumanyika health disparities. Am J Public Health. ples, perhaps for fear of stirring 24. Singh GK, Kogan MD. Widening also played a major role in writing the text 2010;100(suppl 1):S47---S51. socioeconomic disparities in US child- political opposition, because of and a lead role in responding to external 7. Bloche MG. Health care disparities--- hood mortality, 1969-2000. Am J genuine differences in values or reviewer comments. J. Fielding, T. LaVeist, science, politics, and race. N Engl J Med. Public Health. 2007;97(9):1658--- L. N. Borrell, R. Manderscheid, and 2004;350(15):1568---1570. because of the prevailing ethos 1665. A. Troutman also contributed conceptually that enjoins researchers to avoid and participated in substantive revisions 8. Steinbrook R. Disparities in health 25. Singh GK, Siahpush M. Widening throughout the process. care---from politics to policy. N Engl J Med. socioeconomic inequalities in US life ex- the realm of values that might 2004;350(15):1486---1488. pectancy, 1980-2000. Int J Epidemiol. compromise the integrity of their 2006;35(4):969---979. 9. Braveman P. Health disparities and science. Scientists, like all others, Acknowledgments health equity: concepts and measurement. 26. Fielding J, Kumanyika SK. Recom- We wish to thank Karen Simpkins, MLS, should be guided by ethical and Annu Rev Public Health. 2006;27:167--- mendations for the concepts and form of and Colleen J. Barclay, MPH, for their 194. Healthy People 2020. Am J Prev Med. human rights values. The first assistance with research. Written permis- 10. Daniels N, Kennedy B, Kawach I. 2009;37(3):255---257. decade of the 21st century has sion has been obtained from all persons named here. The authors take full re- Justice is good for our health. Boston 27. Beyond Health Care. New Directions ended with little if any evidence sponsibility for the contents of this paper Review 2000 February/March 25(1): to a Healthier America. Recommendations of progress toward eliminating as individuals. This article is not an official 4---19. from the Robert Wood Johnson Foundation report from the SAC or from the sub- Commission to Build a Healthier America. health disparities by race or so- 11. Wagstaff A, van Doorslaer E. Equity committee to the SAC. in health care finance and delivery. In: Washington, DC: Robert Wood Johnson cioeconomic status.22 It is time to Note. The research presented here Foundation Commission to Build a Culyer S, Newhouse J, eds. 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None of the 29. Gruskin S, Mills EJ, Tarantola D. 14. Braveman P, Gruskin S. Defining History, principles, and practice of health Paula A. Braveman is with the University authors received compensation for this equity in health. J Epidemiol Community and human rights. Lancet. 2007;370 of California, San Francisco. Shiriki work. The authors take full responsibil- Health. 2003;57(4):254---258. (9585):449---455. Kumanyika is with University of ity for the material. Pennsylvania School of Medicine, 15. Braveman P, Starfield B, Geiger HJ. 30. Yamin AE. Shades of dignity: ex- Philadelphia. Jonathan Fielding is with the World Health Report 2000: how it ploring the demands of equality in ap- University of California, Los Angeles, Human Participant Protection removes equity from the agenda for plying human rights frameworks to School of Public Health. Thomas LaVeist is No institutional review board approval public health monitoring and policy. BMJ. health. 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