Book Review

Challenging Inequities in Health: From Ethics to Action

N Engl J Med 2001; 345:1857-1858December 20, 2001

Article

Challenging Inequities in Health: From Ethics to Action
Edited by Timothy Evans, Margaret Whitehead, Finn Diderichsen, Abbas Bhuiya, and Meg Wirth. 368 pp., illustrated. New York, Oxford University Press, 2001. $37.95. ISBN: 0-19-513740-X

Counters and classifiers of deaths and diseases, including demographers and epidemiologists, have long been fascinated with the statistical regularities of social inequalities in morbidity and mortality. The earliest studies of social class and mortality coincided with the development of the life table in the 1600s. Interest in the subject has waxed and waned over the centuries, stimulated in part by economic conditions and political movements. In the context of growing economic inequalities during the past decade, the demise of the Soviet Union, and the dominance of capitalism under the military and ideological leadership of the United States, academic interest in inequalities in health has grown rapidly. Challenging Inequities in Health is an attempt to summarize the theoretical and quantitative work on health inequalities, in the context of ethical considerations, for the purpose of reaching national and international policymakers. The book is a project of the Global Health Equity Initiative, an international group of scholars with strong connections to the Harvard Center for Population and Development Studies in Cambridge, Massachusetts, the King's Fund in London, and the Bellagio Study Center in Bellagio, Italy.

A large part of the book is devoted to analyses of health inequalities in specific countries. Although the quantitative analyses, particularly in the case of developed countries such as the United States, Britain, and Sweden, cover familiar ground, chapters devoted to South Africa, Tanzania, Russia, China, and Bangladesh, among others, give a broad international perspective and a variety of methods that derive, in part, from a lack of population-based data on morbidity and mortality. The chapter on Japan provides historical perspectives on social, economic, and health indicators for that nation as well as comparisons with other countries. Together, the country-specific chapters, although not intended to be comprehensive, provide an interesting sampling of research on health inequalities around the world.

The greatest tensions in the book occur over issues of ethics and policy. In their introductory chapters, the editors distinguish health inequality — differences in disease rates among social groups — from health inequity, defined as those inequalities that are unfair. The attention given to this distinction is useful, because it highlights the ethical issues inherent in quantitative studies of health inequalities that have received inadequate attention in the past from epidemiologists, demographers, and health policy analysts. As Peter and Evans note in their chapter on ethical dimensions of health equity, “A comprehensive theoretical framework for health equity analysis faces the challenge of bridging moral and political philosophy and epidemiology.” Among the ethical theories considered by Peter and Evans, the work of philosopher John Rawls provides the most sophisticated basis for evaluating equity by defining fairness as an outcome of basic social, economic, and political institutions that are not exclusive. From this perspective, differences in health that arise from the victimization of some social groups by others through institutions that do not meet the basic requirements of fair social cooperation can be considered inequities in health. The authors of the book explore how inequalities in morbidity and mortality according to sex, race, and class are connected to social institutions through mechanisms involving differential exposure to adequate nutrition, safe living and working conditions, educational opportunities, and medical services.

Unfortunately, this useful theoretical basis for bridging ethics and epidemiology is undermined in most of the book by the use of functionalist social-science theory in which dominant economic and political arrangements are not subjected to critical analysis. References to the importance of social justice and to health as a basic human right appear to be more rhetorical than substantive in the context of assumptions that political efforts to reduce power differentials are “unrealistic” and that the present form of economic globalization is “inescapable because it corresponds to the present phase of historical development.” Chapter authors identify, for example, the inequity inherent in the fact that, under current health care systems, the fewest medical services go to segments of the population with the greatest needs, and pharmaceutical companies have little motivation to focus on diseases of the poor. Yet the for-profit status of the medical care and insurance industries receives little attention as an explanation of health inequities or as a possible target for changes in policy.

Functionalist social theory can be contrasted with conflict-based theories developed in Europe and prominent in analyses of health inequalities from Brazil, Argentina, Ecuador, and Mexico. Instead of viewing health inequities as controllable side effects of the lack of democracy that accompanies vast inequalities in power between social groups, conflict-based theories consider the health states of dominant and subordinate social groups to be causally related to each other through relationships of exploitation. Although this perspective is not commonly invoked by the authors of Challenging Inequities in Health, its power is evident in the chapter by Gilson and McIntyre on the health consequences of apartheid in South Africa, which describes how “the creation and maintenance of a cheap labor system to secure industrial profits . . . was achieved by forcing the majority of the black population to live in specified rural areas and then limiting their access to urban areas as part of the broader control over the employment opportunities offered to black, colored, and Indian people.” The authors report that “61 percent of the black, 38 percent of the colored, five percent of the Indian, and only one percent of the white population” live in poverty. They document the effects of this system on employment, education, environmental conditions, infant mortality, and diarrhea.

This book opens the door to a fundamental debate about how to reduce health inequalities by discussing ethics and policy. However, by restricting the potential partners of health researchers to policymakers in governments and international bodies, the book limits its attention to modest, incremental policy changes that might be implemented in the context of current global and national economic relations. Health inequalities are to be explained and reduced through policies enacted by elite segments of dominant social groups, assuming that members of these groups will be motivated to improve basic living and working conditions for subordinate groups because those conditions are unethical. Although this is a laudable goal, its success hinges on the assumption that the material basis of health inequalities is unnecessary to the health of current economic systems. If exploitation of inequities in economic relations, race, class, and sex is viewed as key to the health of current economic systems, the managers of these systems cannot be expected to bring about fundamental changes in order to reduce inequities in health. Quantification of social inequalities in health, however sophisticated, cannot provide the tools to fix problems that are inherently ethical and political.

An alternative approach to “bridging moral and political philosophy and epidemiology” is to recognize that popular struggles for democracy, including the women's, civil rights, anti-apartheid, and labor movements, have a tremendous potential to affect the root causes of health inequalities by improving living conditions and access to services for groups with the poorest health status. Partnerships between medical and public health researchers and groups suffering from social inequities can identify research needs and provide quantitative analyses that can be used by communities involved in movements for democratic social change. Such partnerships, which require clinicians, epidemiologists, and health policy analysts to establish working relationships with groups outside elite institutions, have the potential to enrich the hypotheses, methods, substantive content, and policy implications of research on disparities in health. Although Challenging Inequities in Health does not explicate a model of improved equity in health based on the empowerment of socially disadvantaged groups, it does show why such an approach is important.

Steve Wing, Ph.D.
University of North Carolina at Chapel Hill, Chapel Hill, NC 27599-7435
steve_wing@unc.edu