PUB576001 Adelphi University Health Disparities and Health Equity Response You will write a response paper with the following formatting requirements: 1200
PUB576001 Adelphi University Health Disparities and Health Equity Response You will write a response paper with the following formatting requirements: 1200-1,500 words, 1 inch margins, 12 point Times New Roman, double spaced, APA-style referencing. Papers must have at least 3 references not including the article/book being reviewed. Write a response paper about Health Disparities and Health Equity: The Issue Is Justice. Response Paper (10%). You will write a response paper with the following formatting
requirements: 1200-1,500 words, 1 inch margins, 12 point Times New Roman, double spaced,
APA-style referencing. Papers must have at least 3 references not including the article/book
being reviewed.
General Review Guidelines
I. Summary/Synopsis of what you are responding to (no more than 4 sentences)
A. Identify the basic information about the article/book/video, including:
Title and author of the article
Tell what the article is about
II. Analysis/Evaluation of the strengths and weaknesses of the article/book/video
A. Answer questions which may include:
-Was the article/book/video convincing? Why or why not?
-Do the results/conclusions match the purpose of the study/video?
– Is the study theory-driven?
-Were the methods to carry out the study clearly stated (if applicable)?
-Is the article/book/video one-sided or present a balanced view?
-Does the author(s) draw logical conclusions?
-How does the paper/book/video relate to what has been discussed in class?
-Can additional class article references be used to support the authors
perspective?
III. Write about your personal impressions and identify insights (personal/professional)
that shape your perspective.
A. Reflect upon your reading experience and answer questions which may include:
-Did the article/book/video hold your interest? Why or why not?
-Did the article/book/video frustrate you? Why or why not?
-Are there similarities and/or contradictions to what you have experienced?
-What do you think the article/book/video suggests about your
role/responsibilities as a health professional?
-What new information did you learn as a result of reading the article/book/video?
-What question(s) does the article/book/video raise for you?
B. Include statements such as:
-I was moved by
; In my opinion
The author seems to
Each paper is assessed at 10 points and will be graded for:
a) Mechanics: grammar/spelling, format requested (4points);
b) Insight: evidence that you read and understand the article/book/video; thoughts are logically
ordered and connected (4points);
c) APA style References: to readings, class discussions or experience (2points).
TOWARDS ENVIRONMENTAL JUSTICE AND HEALTH EQUITY
Health Disparities and Health Equity: The Issue Is Justice
Eliminating health disparities is a Healthy People goal. Given the diverse
and sometimes broad definitions of health disparities
commonly used, a subcommittee convened by the
Secretarys Advisory Committee for Healthy People
2020 proposed an operational definition for use in
developing objectives and
targets, determining resource allocation priorities,
and assessing progress.
Based on that subcommittees work, we propose
that health disparities are
systematic, plausibly avoidable health differences adversely affecting socially
disadvantaged groups; they
may reflect social disadvantage, but causality need
not be established. This definition, grounded in ethical
and human rights principles, focuses on the subset
of health differences reflecting social injustice,
distinguishing health disparities from other health
differences also warranting
concerted attention, and
from health differences in
general.
We explain the definition,
its underlying concepts, the
challenges it addresses, and
the rationale for applying it to
United States public health
policy. (Am J Public Health.
2011;101:S149S155. doi:10.
2105/AJPH.2010.300062)
Paula A. Braveman, MD, MPH, Shiriki Kumanyika, PhD, MPH, Jonathan Fielding, MD, MPH, MA, MBA,
Thomas LaVeist, PhD, Luisa N. Borrell, DDS, PhD, Ron Manderscheid, PhD,
and Adewale Troutman, MD, MPH, MA
ONE OF 2 OVERARCHING
goals of Healthy People 20101 was
to eliminate health disparities
among different segments of the
population. A similar goal to
achieve health equity and eliminate health disparities was proposed by the Health and Human
Services Secretarys Advisory
Committee (SAC) for Healthy People 2020.2 Healthy People 2010
noted that health disparities include differences that occur by
gender, race or ethnicity, education or income, disability, living in
rural localities, or sexual orientation.1 However, the rationale for
identifying disparities in relation
to these particular population
groups was not articulated. The
National Institutes of Health defined health disparities as differences in the incidence, prevalence,
mortality, and burden of diseases
and other adverse health conditions that exist among specific
population groups in the United
States3,4; several other federal
agencies have similarly broad
definitions.5 The lack of explicit
criteria for identifying disparities
in Healthy People 20101 and the
relatively nonspecific definitions
of disparities used by federal
agencies3,4 leave considerable
room for ambiguity as to what
other groups might also be relevant.
Furthermore, there has been
controversy as to whether definitions of health disparities should
imply injustice or simply reflect
differences in health outcomes
that might apply to any United
States population segment.6—8 Different ethical, philosophical, legal,
Supplement 1, 2011, Vol 101, No. S1 | American Journal of Public Health
cultural, and technical perspectives may generate different definitions of health disparities or inequalities (the most comparable
term outside the United States).9—21
For example, in the United Kingdom, Whitehead defined health
inequalities as differences that are
unnecessary, avoidable, and unfair.21 This definition is widely
used internationally, where
health inequalities are assumed
to be socioeconomic differences
unless otherwise specified; in the
United States, however, health
disparities more often refer to
racial or ethnic differences.
Effective public policies require
clear and contextually relevant
operational definitions to support
the development of objectives and
specific targets, determine priorities for use of limited resources,
and assess progress. The need for
clear definitions is particularly
compelling given the lack of progress toward reducing racial/ethnic
and socioeconomic disparities in
medical care22 and health.23—25
Recognizing the practical implications of lack of clarity on this
critical issue, the SAC convened
a subcommittee to define health
disparity and health equity for
use in Healthy People 2020.2 The
subcommittee members, including
both SAC members and external
experts, wrote this paper to elaborate on the definitions and explain their rationale.2,26 These definitions (see the box on the next
page) and the rationale presented
are substantively consistent with
those adopted by the SAC and recently published in Healthy People
2020,2 but reflect some changes in
wording. Clarifying these concepts
will enable medical and public
health practitioners and leaders to
be more effective in reducing disparities in medical care and in
advocating for social policies (e.g.,
in child care, education, housing,
labor, and urban planning) that
can have major impacts on population health.27
UNDERLYING VALUES AND
PRINCIPLES
The concepts of health disparities and health equity are rooted
in deeply held American social
values and pragmatic considerations, as well as in internationally
recognized ethical and human
rights principles.9 Drawing on
ethical and human rights concepts,
key principles underlying the
concepts of health disparities and
health equity include the following:
All people should be valued
equally. This concept was articulated by Jones et al.28 as foundational to the concept of equity. Equal worth of all human
beings is at the core of the
human rights principle that all
human beings equally possess
certain rights.29,30
Health has a particular value for
individuals because it is essential
to an individuals well-being
and ability to participate fully in
the workforce and a democratic
society. Ill health means potential
suffering, disability, and/or loss
of life, threatens ones ability to
earn a living, and is an obstacle
to fully expressing ones views
and engaging in the political
Braveman et al. | Peer Reviewed | Environmental Justice | S149
TOWARDS ENVIRONMENTAL JUSTICE AND HEALTH EQUITY
process. The Nobel Laureate
economist Amartya Sen31
viewed health as a fundamental
capability required to function
in society; similarly, ill health
can be a barrier to fully realizing ones human rights.
Because ill health can be an
obstacle to overcoming disadvantages, health disparities,
which further disadvantage socially disadvantaged groups,
seem particularly unfair.
Nondiscrimination and equality.
Every person should be able to
achieve his/her optimal health
status, without distinction based
on race or ethnic group, skin
color, religion, language, or nationality; socioeconomic resources or position; gender,
sexual orientation, or gender
identity; age; physical, mental,
or emotional disability or illness; geography; political or
other affiliation; or other characteristics that have been linked
historically to discrimination or
marginalization (exclusion from
social, economic, or political
opportunities). The groups represented by these characteristics
substantively agree with those
specified by the United Nations
Committee on Economic, Social
and Cultural Rights as vulnerable groups whose rights are at
particular risk of being unrealized, due to historic discrimination.32 This directly reflects the
human rights principles of
nondiscrimination and equality;
nondiscrimination includes
not only intentional but also
unintentional or de facto
discrimination, meaning discriminatory treatment embedded in structures and institutions, regardless of whether
there is conscious intent to discriminate.32,33 The late philosopher John Rawls19 advanced
the concept of a societys ethical
Health Disparities and Health Equity
Health disparities are health differences that adversely affect socially disadvantaged groups.
Health disparities are systematic, plausibly avoidable health differences according to race/ethnicity,
skin color, religion, or nationality; socioeconomic resources or position (reflected by, e.g., income,
wealth, education, or occupation); gender, sexual orientation, gender identity; age, geography,
disability, illness, political or other affiliation; or other characteristics associated with discrimination
or marginalization. These categories reflect social advantage or disadvantage when they determine
an individuals or groups position in a social hierarchy (see the box on the next page).
Health disparities do not refer generically to all health differences, or even to all health differences
warranting focused attention. They are a specific subset of health differences of particular relevance
to social justice because they may arise from intentional or unintentional discrimination or
marginalization and, in any case, are likely to reinforce social disadvantage and vulnerability.
Disparities in health and its determinants are the metric for assessing health equity, the principle
underlying a commitment to reducing disparities in health and its determinants; health equity is
social justice in health.
obligation to maximize the wellbeing of those worst off. An
aversion to discrimination is
also firmly rooted in United
States policies, as exemplified by
the Civil Rights Act of 1964
prohibiting discrimination on
the basis of race, color, or national origin; the 1954 Brown
vs. Board of Education decision
desegregating schools; the Hill
Burton Act of 1946 prohibiting
hospitals receiving federal funds
from discriminating on the basis
of race, color, or creed; and the
Americans with Disabilities Acts
of 1990 and 2008 prohibiting
discrimination on the basis of
physical or mental disability.
Health is also of special importance for society because a nations prosperity depends on the
entire populations health.
Healthy workers are more productive and generate lower annual medical care costs.34—36
A healthier population has
more workers available for the
workforce. Health can facilitate
political participation, which
is essential for democracy.
Rights to health and to a standard
of living adequate for health. International human rights agreements, to which virtually all
countries are signatories, obligate
S150 | Environmental Justice | Peer Reviewed | Braveman et al.
governments to respect, protect,
fulfill, and promote all human
rights of all persons, including
the right to the highest attainable standard of health and the
right to a standard of living
adequate for health and wellbeing. Governments must demonstrate good faith in progressively removing obstacles to realizing these rights.29 The United
States signed but did not ratify
the International Covenant on
Economic, Social, and Cultural
Rights, which articulated the
right to health. Signing a treaty,
however, is considered an endorsement of its principles and
reflects acceptance of a good
faith commitment to honor its
contents. The right to health
(i.e., the right of everyone to the
enjoyment of the highest attainable standard of physical and
mental health37) is not to be
understood as a right to be healthy, because too many factors
beyond states control influence
health. Rather, it is the right to
a system of health protection
which provides equality of opportunity to enjoy the highest
attainable level of health. It includes the right to equal access to
cost-effective medical care as
well as to child care, education,
housing, environmental protection, and other factors that are
also crucial to health and wellbeing.38
Health differences adversely affecting socially disadvantaged
groups are particularly unacceptable because ill health can be
an obstacle to overcoming social
disadvantage. This consideration
resonates with common sense
notions of fairness, as well as
with ethical concepts of justice,
notably, the concept that need
should be a key determinant of
resource allocation for health,
and Rawls notion of the obligation to maximize the wellbeing of those worst off.39
Sen noted as a particularly serious . . . injustice . . . the lack
of opportunity that some may
have to achieve good health
because of inadequate social
arrangements. . . .40 Sen argued
that health is a prerequisite for
the capability to function normally in society.31 It is therefore
particularly unjust that those
who are socially disadvantaged
should also experience additional obstacles to opportunity
based on having worse health.
Ratifying human rights agreements obliges governments to
direct special effort toward
American Journal of Public Health | Supplement 1, 2011, Vol 101, No. S1
TOWARDS ENVIRONMENTAL JUSTICE AND HEALTH EQUITY
equalizing the rights of vulnerable groups facing more obstacles to realizing their rights. A
nonexhaustive list of vulnerable
groups is specified in human
rights documents on nondiscrimination and equality.32,37,41,42
The resources needed to be
healthy (i.e., the determinants of
health, including living and
working conditions necessary for
health, as well as medical care)
should be distributed fairly. To
do so requires considering need
(along with capacity to benefit16
and efficiency17) rather than
ability to pay or influence in
society.17 This principle, along
with principles cited previously,
reflects the ethical notion of
distributive justice (a just distribution of resources needed for
health) and the human rights
principles of nondiscrimination
and equality, as well as the
right to a standard of living adequate for health. Investments
in medical care intended to
reduce disparities must be
weighed against other potentially more effective investments that address disparities
in other health determinants.38
Health equity is the value underlying a commitment to reduce and
ultimately eliminate health disparities. It is explicitly mentioned in the Healthy People
2020 2 objectives. Health equity means social justice with
respect to health and reflects the
ethical and human rights concerns articulated previously.
Health equity means striving to
equalize opportunities to be
healthy. In accord with the
other ethical principles of beneficence (doing good) and
nonmalfeasance (doing no
harm), equity requires concerted effort to achieve more
rapid improvements among
those who were worse off to
start, within an overall strategy
to improve everyones health.
Closing health gaps by worsening advantaged groups health is
not a way to achieve equity.
Reductions in health disparities
(by improving the health of the
socially disadvantaged) are the
metric by which progress toward health equity is measured.
although a causal link need not be
demonstrated. Differences among
groups in their levels of social
advantage or disadvantage, which
can be thought of as where
groups rank in social hierarchies,
are indicated by measures
reflecting the extent of wealth,
political or economic influence,
prestige, respect, or social acceptance of different population
groups.
HEALTH DISPARITIES:
DEFINITION AND
RATIONALE
Systematic But Not
Necessarily Causal Links With
Social Disadvantage
We briefly define health disparities and health equity (see the
box on the previous page), elaborating further and explaining in
this section. We also discuss social
disadvantage, a key concept for
understanding disparities and equity (see the box on this page).
Health disparities are systematic,
plausibly avoidable health differences adversely affecting socially
disadvantaged groups. They
may reflect social disadvantage,
As noted by Starfield,45 health
disparities are systematic, that is,
not isolated or exceptional findings. Health disparities are systematically linked with social disadvantage, and may reflect social
disadvantage, although a causal
link does not need to be demonstrated. Whether or not a causal
link exists, health disparities adversely affect groups who are already disadvantaged socially, putting them at further disadvantage
with respect to their health,
thereby making it potentially more
difficult to overcome social disadvantage. This reinforcement or
compounding of social disadvantage is what makes health disparities relevant to social justice even
when knowledge of their causation is lacking. It is important to
define health disparities without
requiring proof of causality, because there are important health
disparities for which the causes
have not been established, but
which deserve high priority based
on social justice concerns. For
example, the large Black—White
disparity in low birth weight
and premature birth strongly predicts disparities in infant mortality
and child development, and
likely in adult chronic disease.46
Although the causes of racial
disparity in birth outcomes are
not established,46 credible scientific
sources have identified biological mechanisms that plausibly
contribute to the disparities,46—50
which reflect phenomena shaped
by social contexts and thus are, at
least theoretically, avoidable.
Social Disadvantage
Health disparities and health equity cannot be defined without defining social disadvantage.
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.
It means restricted ability to participate fully in society and enjoy the benefits of progress. Social
disadvantage is reflected, for example, by low levels of wealth, income, education, or occupational
rank, or by less representation at high levels of political office. Criteria for social disadvantage can
be absolute (e.g., the federal poverty threshold in the United States is based on an estimate of the
income needed to obtain a defined set of basic necessities for a family of a given size)43 or relative
(e.g., poverty levels in a num…
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