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Vol. LXVI, No. 12
June 6, 2014
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Disparity Definition Needs Tightening, Braveman Says

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Dr. Paula Braveman gives lecture for National Minority Health Month.
Dr. Paula Braveman gives lecture for National Minority Health Month.
If the rich people in city A have higher rates of an illness than the rich people in city B, this qualifies, under current NIH criteria, as a health disparity.

Similarly, skiers have higher rates of bone breaks and fractures than non-skiers. “Does that fill you with moral outrage?” asked Dr. Paula Braveman, professor of family and community medicine and director of the Center on Social Disparities in Health at the University of California, San Francisco.

At her recent keynote talk marking National Minority Health Month, Braveman discussed the range of values informing the field of health disparities, a term coined in the 1990s. A student for more than 25 years of the social determinants of health, she called for a fresh consideration of what constitutes a health disparity, based on international human rights principles that have been endorsed (but not necessarily fulfilled) by nearly all nations.

Disparities, she argued, are health differences that are unfair in a particular way. As the ski example shows, not all health differences are unfair. Braveman favors a definition of disparity enunciated by British social scientist Dr. Margaret Whitehead, who says we ought to focus not just on any differences in health status among any groups, but on those that are “unfair, avoidable and unjust.”

Continued...

Braveman acknowledged that the National Institute on Minority Health and Health Disparities is faced with a dizzying array of needs, difficult to balance. Should NIMHD focus on autism? People with catastrophic genetic diseases? Veterans? Men, who have a shorter life expectancy than women?

Human rights principles provide guidance, Braveman said. She argues that people have the right to attain the highest possible standard of health, the right to education, the right to a decent standard of living (needed for health), to the benefits of progress, to non-discrimination and to equality of rights.

Proceeding from these rights, which are globally accepted even if not always achieved, are economic, social and cultural rights that cannot be separated from the civil and political rights with which most of us are more familiar, e.g., freedom of speech.

“A group’s history of exclusion and marginalization,” from such rights should be an important factor in defining a disparity, she said.

The obligation of a just society is to focus on those with the greatest social and economic obstacles to fulfilling their rights, Braveman said.

The obligation of a just society is to focus on those with the greatest social and economic obstacles to fulfilling their rights, Braveman said.

Photos: Bill Branson

Braveman proposes a human rights-based definition of health disparities, which are closely linked to social and economic disparities. We need to focus on those disparities that adversely affect groups who have experienced greater obstacles to health, she said.

“Not all health differences are health disparities,” she said. “The key is ‘What adversely affects socially disadvantaged groups?’ When you put already socially disadvantaged groups at further disadvantage with respect to health, that’s a double-whammy.”

Braveman’s talk, “Health Disparities: The Issue Is Justice,” made the case that equity is justice. “Disparities or inequalities are the metric we use to assess progress toward equity.”

The obligation of a just society is to focus on those with the greatest social and economic obstacles to fulfilling their rights, she said.

Braveman acknowledged that the causes of many health disparities are unknown, “including many important ones.” She also noted that if you count up all the vulnerable groups within the United States, it turns out to include “most of the population,” which is clearly untenable as a focus for NIMHD.

She called for a focus on groups that have historically experienced discrimination or marginalization. We should consider the depth and duration of the disadvantage, including which groups have experienced atrocities, slavery, Jim Crow and intergenerational poverty.

“There are measurement challenges, too,” she said. What is the reference group for comparison? She set a high bar—the health of the most socially privileged group, i.e., those with the greatest wealth, power and prestige, arguing that that indicates what should be biologically possible for everyone.

Braveman’s espousal of human rights values and concepts springs from both the accumulated gravity of ideas accepted around the world and from a sense that such principles conceive of health equity as an entitlement, not as a charity.

Only a values framework that sets its benchmark at the highest attainable standard of health can hope to interrupt a vicious cycle of harmful exposures, vulnerability and unequal consequences, she maintains.

“Pursuing equity requires swimming against prevailing tides,” she concluded. “We will encounter resistance. We therefore need to be very clear about where we are headed and why.”


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