Article Text

Download PDFPDF

Is equity a scientific issue?
  1. The Johns Hopkins University (e-mail: bstarfie{at}
  2. Facultad de Ciencias Medicas, UNLP, Argentina (e-mail:isequity{at}
    1. The Johns Hopkins University (e-mail: bstarfie{at}
    2. Facultad de Ciencias Medicas, UNLP, Argentina (e-mail:isequity{at}

      Statistics from

      Request Permissions

      If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.

      Equity is a humanitarian issue that derives from principles of ethics, especially justice (fairness). Fairness requires the elimination of inequity—that is, systematic inequality across population subgroups. Can science be brought to bear on the subject of equity? The answer must be yes. This is the rationale for the new International Society for Equity in Health (ISEqH).

      It is no secret that, in the world over and within countries, the rich are getting richer and the poor are getting poorer. Ethical issues alone suggest a cause for alarm, on humanitarian grounds. Concern is heightened by the relatively recent evidence that increasing poverty is not the only worry. Although it is a big one, it is not a new one. The new issue concerns the evidence of increasing inequities in wealth wherein the ill effects derive not only from increases in poverty but also because the wealthier are becoming wealthier.

      Recent literature is converging on the conclusion that the extent of disparities between the wealthiest segments of society and the less wealthy is directly related to the health of that society, even when health is measured by conventional mortality and morbidity statistics. Thus, the phenomenon is not a matter only of material deprivation among the poorer segments of society,1-3 and it is not alleviated substantially by providing alms (either public or private) to lighten the burden on the poor.

      The determinants of ill health, whether in an individual or a population sense, are many. A parsimonious depiction of the variety of types of “causes” of ill health is provided in figure 1. Missing from the figure are the important influences of genetics and biology, as well as the pathophysiological mechanisms through which the depicted phenomena operate to increase or decrease risks to illness. Also missing are the innumerable interactions that undoubtedly exist between and among the depicted characteristics. Unrecognised in this two dimensional framework is the influence of time and trajectories over the life course. The influence on adult health of events in very early life and continuing through childhood are now undeniable, although the mechanisms of the trajectories are still unclear. Does early damage always increase risk of subsequent pathology and under what conditions might it not? Might the effects of early insults be occult, only to be manifested later? Are they mostly gradually accumulating, with each increment leading to progressively greater risks to health later on? Or are there vulnerable “incubation” periods during which people are particularly susceptible to incurring risks that will be manifested later on?

      Figure 1

      A conceptual framework of health determinants.

      We are also beginning to suspect that the pathway of determinants does not act in the same way in all countries, all cultures, and in all population subgroups. For example, in the US, mortality in black populations in urban areas seems much more heavily influenced by income inequality than is the case in white urban populations, in which the adverse effect of income inequalities is partly mitigated, for example, by greater availability of primary care health services (submitted data).

      The findings regarding the likely importance of primary care in reducing the effect of income inequality, at least in some areas and populations in the US4 run counter to the widely held belief that health services do have much effect on health. Only a few studies5 6 provide any hope for the potential benefits of health services taken together. However, newer conceptualisations of “health services” have brought the realisation that health services are composed of two quite distinct parts: primary care and specialty care and, at least in terms population health, it is primary care and not specialty care that makes the most contribution.7

      The subject of causation of inequities in health is clearly complex, but it is amenable to scientific study. The many issues concerning the nature of the pathways in different population groups, in different cohorts, and in different historical time periods are only some of the many challenges. We need lots of good science on the nature of the pathways and their consistency and variability, on the best ways to specify the variables that represent the various types of characteristics in the theoretical models, on the relative impact and mechanisms of effect of various types of interventions to reduce the effects on ill health and perhaps even improve health of populations, and on the special challenges posed by particularly vulnerable population groups such as children and adolescents, women and especially pregnant women, and racial and ethnic minorities. Development and application of statistical techniques that elucidate mechanisms rather than describing them (as in standard multivariate regression approaches) are also a high priority, as are collaborative efforts across political jurisdictions and countries, in order to improve the generalisability of research results and policy applications.

      For this reason, we have formed the International Society for Equity in Health (ISEqH), which will hold its inaugural meeting in Havana, Cuba, on 29–30 June 2000.

      The following is taken from the Principles Declaration for the Society.

      “The purpose of the Society is to encourage advances in knowledge about the importance of equity in the improvement of health of all people, and to promote the application of knowledge to activities directed at this goal. Its primary but not exclusive focus is on the contributions made by health services as a critical social endeavor. Its purposes are

      • to promote equity in health and health services internationally

      • to facilitate scientific interchange of conceptual and methodological knowledge on issues of equity

      • to advance research related to equity in health

      • to foster leadership networking for equity in health

      • to maintain corresponding relationship with other relevant international and regional organizations

      An equitable society is the foundation for achieving equity in health, including social justice in a participatory process, economic development as one means to attain the goal of social justice, and policy decisions and actions towards equal opportunities. Accordingly, the level of health achievable by individuals requires a process by which health knowledge, health sciences, and health systems and services play an important part, together with other social and economic forces, and in close association with community forces.

      The Society assumes that there is a need for a scientific non-governmental organization with the major purpose to discuss, analyze, and propose health actions to achieve equity in health.”

      Since March 1999, with only e-mail correspondence, over 400 people in over 40 countries have expressed their interest in joining the Society and attending the meeting in June 2000.