Inequalities in Health: Concepts, Measures, and Ethics

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  4. What does the empirical evidence tell us about the injustice of health inequalities?

For example, when the GINI index, which is one of the most frequently used methods to measure social inequality within a country, is calculated globally it results in even higher levels than those found in nations with the highest levels of social inequality.

In recent years, the GINI indices of countries with the highest levels of inequality have been around 0. The global GINI index captures the extremes of the poorest strata of the poorest countries and the richest strata of the richest countries, which translates into a higher level of inequality than when measured in each country separately.

The aim of this article is to present health inequalities as a global problem that affects the populations of poor countries, but also those of rich countries, and the continuation of these inequalities demonstrates the historical and structural roots of this problem. Although this discussion is related to discussions about poverty and health, it has a different, more specific dimension.

Health inequalities are undoubtedly one of the most relevant problems in the field of population health and they represent a challenge to those who seek to overcome them.

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For many, health is understood as being restricted to biological factors; for others, it is a complex phenomenon with multiple determinations that are based on the way people live and are organized. For a long period these two explanatory theories have formed the basis for discussions, and they have competed to provide plausible explanations about the health conditions of human populations 9 - The relevance of this debate is that it defines the manner in which societies organize themselves to solve their health problems.

The former theory is based on the development of biomedical sciences and their explanations of the mechanisms of diseases, as well as alternatives to correct them. It focuses on the search for a detailed understanding of human biology in the expectation that this will provide the necessary explanations to understand how human health disorders occur and how they can be corrected. The development of this system has been accelerated by advances in biomedicine and resulting technologies, especially since the second half of the twentieth century.

The latter theory precedes the development of biomedicine and argues that there is accumulated evidence that changes in economic, social, political, environmental, cultural or behavioral contexts affect the health conditions of individuals and populations 11 - Conceptions about the social determination of health and disease developed during the nineteenth century and they were expressed in the works of important thinkers who were mainly located in Europe.

These pioneers established the idea that the health conditions of populations are directly related to the context in which they live, and the position of individuals in the social pyramid. Because we live in an age when these two theories coexist, and biomedical sciences and health services are both growing and strengthening, it is evident that these theories are in competition with each other.

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Health services, as they are currently organized, play an important role in curing and rehabilitating many of the pathological processes that afflict individuals. For example, prevention actions such as the use of vaccines and screening methods for the early diagnosis and reduction of damage from pathological processes are already available.

However, they have few resources to deal with the social and environmental determinants that are the source of many of the health problems affecting individuals and populations. With limited exceptions vaccine-preventable diseases there has been little action regarding the incidence of health events. This dispute has fueled a prolonged debate regarding the importance of each of these theories in relation to the health conditions of human populations. The most elaborate contribution was by Thomas McKeown, who from wrote an important body of scientific work which argued that medical technology and the health system played a secondary role in the important and positive changes that occurred in the health conditions of the English population from the late nineteenth century until the second half of the twentieth century 17 , McKeown argued that these transformations could be explained by improvements in general living standards, especially in terms of diet and nutritional status, which were the result of better economic conditions.

As in the case of England, health conditions in many countries which are now developed also had their greatest turning point, for the better, over the same period. For much of this period, most of the preventive, diagnostic or therapeutic resources for the diseases and health problems that exist today were not available.

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These technologies were only invented in the s and they were only used in a large-scale in health systems from the s Although some of the arguments put forward by McKeown have not been fully confirmed, especially his emphasis on the role of diet and nutrition, his argument about the secondary role of biomedical technologies has had widespread repercussions 10 , While health technologies have had been intensely developed over the last decades, and some of them highly effectively, arguments about the importance of technologies and the health system transforming the health conditions of populations have not been empirically demonstrated.

After the massive introduction of biomedical technologies and the expansion of health systems, this type of research has become subject to interpretative confusion. At the moment that the two effects social determinants and biomedical technologies became active there were clear methodological difficulties in separating the effect of each of them. However, reinforcing the thesis of social determination, in this same group of developed countries, despite the advances in systems and levels of health that have been observed, important differences persist in health conditions when their populations are stratified by geographic areas or social or ethnic groups 5.

In addition, periods of crisis are often accompanied by worsening health conditions in the populations of these countries. For example, events such as the disintegration of the former Soviet Union, or the financial crisis of which led many European countries to economic recession and the implementation of austerity policies, were followed by worsening health conditions for their respective populations The study of historical trends in the health conditions of populations remains an important source of evidence for the social determination of health and disease, as well as health differentials between countries.

A research program that originated in the economic and demographic sciences has shown a strong relationship between the economic development of countries and health Although it initially focused on economic factors, this line of research was modified to include the effects of different social factors and policies education, public health, etc. As we have seen, since at least the nineteenth century evidence has increased that the health conditions of a population are related to the characteristics of its social and environmental context.

Poverty, poor housing conditions, an inadequate urban environment, and unhealthy working conditions are factors that negatively affect the health conditions of a population. At the end of the nineteenth century, biomedical sciences emerged and began to have an overwhelming influence in providing explanations for health problems and diseases, with social and environmental determinants being secondary.

However, biomedical theories have never adequately explained many phenomena within a population for example, the rich have better health conditions than the poor or between populations in different countries for example, richer countries have better health conditions than poorer countries. With few exceptions, the occurrence of the most diverse diseases and health problems is aggravated for social groups living in socially disadvantaged situations, in other words, for the poorest, ethnic minority groups or groups that suffer any type of discrimination.

It is not by chance that poor countries have worse health conditions compared to rich countries. Likewise, in any given country, whether rich or poor, the poorest regions and the poorest or marginalized ethnic groups consistently have worse health conditions. Further evidence is provided by the fact that when policies which improve economic conditions or strengthen social protection are implemented in any of these countries they have positive impacts on health conditions.

In , the Health Minister of a socialist government appointed a commission led by Douglas Black, who was then president of the Royal College of Physicians, to analyze the existence of health inequalities. This action was taken because the national health system in the UK NHS , which had been created in the s, was founded on the principles of fairness and universal accessibility. One of the relevant observations of this commission was that in the period since the establishment of the NHS there had been major improvements in the health conditions of the British population, regardless of social class actually occupational class.

But the most unexpected finding was that the differentials of health levels between social classes had persisted, and in relation to some problems they had actually widened. Furthermore, inequalities persisted regarding the availability and use of health services.

Health inequality and professional ethics | Professional Ethics

These results were presented in , when the British government was then led by the Conservative party, which not only resisted its publication but also made explicit its non-commitment to the results and recommendations in the prologue of the report. Nevertheless, this document had an immense impact on subsequent discussions regarding health inequalities in developed countries.

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In terms of academic research it rekindled interest in research on inequalities in health, and in the field of politics it stimulated actions by governments regarding this dimension of inequalities. The report explained important moral issues experienced by these societies. It exposed a cruel aspect of capitalism, even at the advanced stages that it had reached in these countries, at a time when these societies would have been expected to be reasonably just in relation to their citizens. At this point it is important to establish the differences between inequalities and inequities in health 24 , Inequalities refer to perceived and measurable differences that exist in health conditions, or are related to differences in the access to prevention, cure or rehabilitation of health inequalities in health care.

Health inequities, on the other hand, refer to inequalities that are considered to be unjust or that stem from some form of injustice. It reflects on a society how it translates existing inequalities and differentiates them into just or unjust ones, and this translation varies among societies. In many societies, huge differentials in health levels between individuals at the top or bottom of the social pyramid are not perceived as being unjust.

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This can happen in developed, poor, or developing countries. Conversely, in other societies relatively small differences in health levels can be translated into a strong public perception of inequity. This happens, for example, in some Scandinavian countries. This issue is important because although inequalities are the subject of discussions in the scientific field and several methods have been developed to measure them, which facilitates comparative studies of health inequalities both within and between societies, it is more difficult to objectively measure inequities because they translate the way that societies perceive and interpret these inequalities, even though it extremely important to understand them.

The conditions for formulating concrete political actions aimed at minimizing existing inequalities emerge at the moment when inequalities become iniquities.

What does the empirical evidence tell us about the injustice of health inequalities?

In recent decades, the growth of the neoliberal perspective and individualism has strengthened the belief that events within society are the responsibility of the individuals who suffer them, minimizing the view of society as a social and collective phenomenon. This perception of the world has been the foundation for influential political forces to interpret inequalities as the fruit of individual problems and to deny that they are an expression of injustice, leading to the argument that there is therefore no need for government policies and actions to minimize them.

However, the issue of social inequalities in health has grown within intellectual and academic debates in recent decades around the world. The availability of data from a variety of sources has uncovered and provided new evidence regarding the extent of health inequalities and, furthermore, shown that in many contexts they are increasing. A few countries especially in Europe have used this evidence to introduce actions based on social determinants into their health policies and to partially reduce inequalities; however, the vast majority have not placed this issue among their political priorities.

At the international level, the importance of social determinants of health became more prominent at the time of the creation of the World Health Organization WHO Commission on Social Determinants of Health. This high-level commission was created by the Director-General of the WHO in with the mission to organize the evidence regarding the actions necessary to promote equity in health at the global level.

The Commission synthesized its recommendations into three central points: 1 to improve daily living conditions; 2 to combat the unequal distribution of power, money and resources; and 3 to measure the magnitude of the problem and evaluate the impact of actions. Studies about health inequality which start from different theoretical foundations in terms of their empirical investigations offer different interpretations and solutions in relation to the problem. Although they have tended to focus primarily on explaining inequalities among social groups within the same nation, similar theoretical foundations can serve as a basis to interpret inequalities between nations and also global inequalities.

To summarize, it is possible to state that these theories are organized into two types of explanations; one based on individuals and another based on structural explanations 5 , The explanations based on individuals are very popular among Anglo-Saxon authors; however, they are grouped into different tendencies and those that stand out are as follows: those that focus on the material dimensions of life, especially regarding the form in which the wealth of society is distributed among its members; those that focus on cultural-behavioral dimensions lifestyles ; and those that emphasize psychosocial dimensions, i.

The psychosocial theory originated in the s and s through the works of John Cassel 29 , However, another line of study, initiated by Richard Wilkinson, constituted a new and interesting evolution of the original theory 31 , Wilkinson developed the idea that inequalities not only determine differences in the material world, and therefore explain pathologies related to various deficiencies e. This concept was subsequently expanded to partially explain existing inequalities among other forms of stratification and discrimination, such as, for example, between genders and ethnicities The structural explanations focus on the idea that the social determinants which generate inequalities in health are shaped by determinants that exist within the superstructure of society, i.

The political definitions that organize the state will also result in political options that will either favor or reduce health inequalities.

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Reinforcing this theory, and providing contrary evidence to those who still believe in distributive possibilities and the consequent reduction of inequalities within the capitalist framework, recent empirical evidence from a study by Piketty 34 shows that capitalist accumulation tends to be differential. It is greater between favoring those who have already accumulated, which results in the expansion of social inequalities.