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Equity in health
  1. B Starfield
  1. School of Public Health, Johns Hopkins University, 624 N Broadway, Room 452, Baltimore, MD 21205, USA
  1. Correspondence to:
 Dr B Starfield;

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Meeting of the International Society for Equity in Health, Havana, Cuba, June 2000

This issue of the Journal of Epidemiology and Community Health contains seven contributions that were originally presented as submitted papers to the first meeting of the International Society for Equity in Health, held in Havana, Cuba, in June 2000.

These contributions, consisting of seven original scientific papers and the keynote address (by Sudhir Anand) are complemented by an additional set of “keynote vignettes” (also presented at the same meeting) to be published in subsequent issues of the journal. (They are short essays on priorities for research on equity in health, prepared by noted researchers in the field.)

The studies reported cover a wide variety of specific topics within the broader topic of equity in health. Two of the eight deal specifically with the meaning of equity in the context of health1,2; two address inequities in health related to inequities in health services3,4; one addresses trends in disparities in infant mortality in the Americas5; two concern inequity consequent to economic transitions6,7; and one discusses the relevance of the genetic revolution to the issue of social class disparities in health.8

All of the papers confront issues, which in one way or another are linked to two subjects of interest to the International Society for Equity in Health, which is devoted to encouraging research in the service of improving policy and practices directed at reducing inequities in health. Towards this end, the society has developed a working definition of equity in health: the absence of systematic and potentially remediable differences in one or more aspects of health across populations or population groups defined socially, economically, demographically, or geographically. This definition expands upon prior definitions9,10 that have focused on fairness of opportunity to achieve health, for the purpose of making explicit the notion that inequities can be measured and tracked over time.

The papers also remind us that considerations of equity require not only attention to manifestations of ill health but also to risks to ill health as well as potential for improved health. This poses a daunting challenge to a research agenda. If equity in health requires equality of opportunities for health, and if these opportunities might be amenable to alterations in policy or practice, it is clearly an imperative that the range of “opportunities” for influence be specified. Influences on health, and therefore on equity in health, are myriad; taking them all into account in trying to sort out those that are amenable to change from those that are not requires that we have both a clear conceptualisation of what they are as well as an idea, or theory, of how they inter-relate and inter-act to provide a cogent pathway for their impact. Although a few such models have been proposed and some 11 widely cited, new knowledge that has subsequently accumulated makes it clear that the range and interaction of determinants is even more extensive than heretofore contemplated.

Figure 1 presents a more recent conceptualisation that attempts to take advantage of new research concerning factors that are associated with increased inequity in health. In contrast with previous schemata, it explicitly recognises that “average” health is not the only concern; distributions of health within and across populations are also relevant. Consistent with recent studies,12 it incorporates the wider ecological context of political and policy characteristics. It places the recently popular “income inequality” research within the more encompassing “economic characteristics”, directly influenced by social and economic policy within defined political jurisdictions. Moreover, it explicitly recognises the need for analyses that are multilevel, in order to take into account characteristics that are aggregated to a population level from individual data; characteristics that reflect the context in which people live and work, and the more distal but still influential characteristics of health policy and politics. The diagram is a “work in progress”, to be refined as more knowledge accumulates.

It is our hope that the formation of the International Society for Equity in Health can move the research and policy agenda further and faster than has been the case in the most recent two decades in which equity has received increasing attention. Comments on the definition and conceptualisation of determinants of health would be most welcome, as would participation in the society by interested parties. Information can be obtained on the web site (

Figure 1

Influences on health at the population level.

Meeting of the International Society for Equity in Health, Havana, Cuba, June 2000