Health Disparities and Health Equity: The Issue Is JusticeEliminating health dis-
parities is a Healthy Peo-
ple goal. Given the diverse
and sometimes broad defi-
nitions of health disparities
commonly used, a sub-
committee convened by the
Secretary’s Advisory Com-
mittee for Healthy People
2020 proposed an opera-
tional definition for use in
developing objectives and
targets, determining re-
source allocation priorities,
and assessing progress.
Based on that subcom-
mittee’s work, we propose
that health disparities are
systematic, plausibly avoid-
able health differences ad-
versely affecting socially
disadvantaged groups; they
may reflect social disad-
vantage, but causality need
not be established. This def-
inition, grounded in ethical
and human rights princi-
ples, focuses on the subset
of health differences re-
flecting social injustice,
distinguishing health dis-
parities 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:S149–S155. 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 disparitiesamong different segments of thepopulation.’’ A similar goal to‘‘achieve health equity and elimi-nate health disparities’’ was pro-posed by the Health and HumanServices Secretary’s AdvisoryCommittee (SAC) for Healthy Peo-ple 2020.2 Healthy People 2010noted that health disparities ‘‘in-clude differences that occur bygender, race or ethnicity, educa-tion or income, disability, living inrural localities, or sexual orienta-tion.’’1 However, the rationale foridentifying disparities in relationto these particular populationgroups was not articulated. TheNational Institutes of Health de-fined health disparities as ‘‘differ-ences in the incidence, prevalence,mortality, and burden of diseasesand other adverse health condi-tions that exist among specificpopulation groups in the UnitedStates’’3,4; several other federalagencies have similarly broaddefinitions.5 The lack of explicitcriteria for identifying disparitiesin Healthy People 20101 and therelatively nonspecific definitionsof disparities used by federalagencies3,4 leave considerableroom for ambiguity as to whatother groups might also be rele-vant.
Furthermore, there has beencontroversy as to whether defini-tions of health disparities shouldimply injustice or simply reflectdifferences in health outcomesthat might apply to any UnitedStates population segment.6—8 Dif-ferent ethical, philosophical, legal,
cultural, and technical perspec-tives may generate different defi-nitions of health disparities or in-equalities (the most comparableterm outside the United States).9—21
For example, in the United King-dom, Whitehead defined healthinequalities as differences that areunnecessary, avoidable, and un-fair.21 This definition is widelyused internationally, where‘‘health inequalities’’ are assumedto be socioeconomic differencesunless otherwise specified; in theUnited States, however, ‘‘healthdisparities’’ more often refer toracial or ethnic differences.
Effective public policies requireclear and contextually relevantoperational definitions to supportthe development of objectives andspecific targets, determine priori-ties for use of limited resources,and assess progress. The need forclear definitions is particularlycompelling given the lack of prog-ress toward reducing racial/ethnicand socioeconomic disparities inmedical care22 and health.23—25
Recognizing the practical implica-tions of lack of clarity on thiscritical issue, the SAC conveneda subcommittee to define ‘‘healthdisparity’’ and ‘‘health equity’’ foruse in Healthy People 2020.2 Thesubcommittee members, includingboth SAC members and externalexperts, wrote this paper to elab-orate on the definitions and ex-plain their rationale.2,26 These defi-nitions (see the box on the nextpage) and the rationale presentedare substantively consistent withthose adopted by the SAC and re-cently published in Healthy People2020,2 but reflect some changes in
wording. Clarifying these conceptswill enable medical and publichealth practitioners and leaders tobe more effective in reducing dis-parities in medical care and inadvocating for social policies (e.g.,in child care, education, housing,labor, and urban planning) thatcan have major impacts on popu-lation health.27
UNDERLYING VALUES ANDPRINCIPLES
The concepts of health dispar-ities and health equity are rootedin deeply held American socialvalues and pragmatic consider-ations, as well as in internationallyrecognized ethical and humanrights principles.9 Drawing onethical and human rights concepts,key principles underlying theconcepts of health disparities andhealth equity include the following:
All people should be valuedequally. This concept was artic-ulated by Jones et al.28 as foun-dational to the concept of eq-uity. Equal worth of all humanbeings is at the core of thehuman rights principle that allhuman beings equally possesscertain rights.29,30
Health has a particular value forindividuals because it is essentialto an individual’s well-beingand ability to participate fully inthe workforce and a democraticsociety. Ill health means potentialsuffering, disability, and/or lossof life, threatens one’s ability toearn a living, and is an obstacleto fully expressing one’s viewsand engaging in the political
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process. The Nobel Laureateeconomist Amartya Sen31
viewed health as a fundamentalcapability required to functionin society; similarly, ill healthcan be a barrier to fully re-alizing one’s human rights.Because ill health can be anobstacle to overcoming disad-vantages, health disparities,which further disadvantage so-cially disadvantaged groups,seem particularly unfair.Nondiscrimination and equality.Every person should be able toachieve his/her optimal healthstatus, without distinction basedon race or ethnic group, skincolor, religion, language, or na-tionality; socioeconomic re-sources or position; gender,sexual orientation, or genderidentity; age; physical, mental,or emotional disability or ill-ness; geography; political orother affiliation; or other char-acteristics that have been linkedhistorically to discrimination ormarginalization (exclusion fromsocial, economic, or politicalopportunities). The groups rep-resented by these characteristicssubstantively agree with thosespecified by the United NationsCommittee on Economic, Socialand Cultural Rights as vulnera-ble groups whose rights are atparticular risk of being unreal-ized, due to historic discrimina-tion.32 This directly reflects thehuman rights principles ofnondiscrimination and equality;nondiscrimination includesnot only intentional but alsounintentional or de factodiscrimination, meaning dis-criminatory treatment embed-ded in structures and institu-tions, regardless of whetherthere is conscious intent to dis-criminate.32,33 The late philos-opher John Rawls19 advancedthe concept of a society’s ethical
obligation to maximize the well-being of those worst off. Anaversion to discrimination isalso firmly rooted in UnitedStates policies, as exemplified bythe Civil Rights Act of 1964prohibiting discrimination onthe basis of race, color, or na-tional origin; the 1954 Brownvs. Board of Education decisiondesegregating schools; the HillBurton Act of 1946 prohibitinghospitals receiving federal fundsfrom discriminating on the basisof race, color, or creed; and theAmericans with Disabilities Actsof 1990 and 2008 prohibitingdiscrimination on the basis ofphysical or mental disability.Health is also of special impor-tance for society because a na-tion’s prosperity depends on theentire population’s health.Healthy workers are more pro-ductive and generate lower an-nual medical care costs.34—36
A healthier population hasmore workers available for theworkforce. Health can facilitatepolitical participation, whichis essential for democracy.Rights to health and to a standardof living adequate for health. In-ternational human rights agree-ments, to which virtually allcountries are signatories, obligate
governments to respect, protect,fulfill, and promote all humanrights of all persons, includingthe ‘‘right to the highest attain-able standard of health’’ and theright to a standard of livingadequate for health and well-being. Governments must dem-onstrate good faith in progres-sively removing obstacles to re-alizing these rights.29 The UnitedStates signed but did not ratifythe International Covenant onEconomic, Social, and CulturalRights, which articulated theright to health. Signing a treaty,however, is considered an en-dorsement of its principles andreflects acceptance of a goodfaith commitment to honor itscontents. The ‘‘right to health’’(i.e., ‘‘the right of everyone to theenjoyment of the highest attain-able standard of physical andmental health’’37) is ‘‘not to beunderstood as a right to be heal-thy,’’ because too many factorsbeyond states’ control influencehealth. Rather, it is ‘‘the right toa system of health protectionwhich provides equality of op-portunity to enjoy the highestattainable level of health.’’ It in-cludes the right to equal access tocost-effective medical care aswell as to child care, education,
housing, environmental protec-tion, and other factors that arealso crucial to health and well-being.38
Health differences adversely af-fecting socially disadvantagedgroups are particularly unac-ceptable because ill health can bean obstacle to overcoming socialdisadvantage. This considerationresonates with common sensenotions of fairness, as well aswith ethical concepts of justice,notably, the concept that needshould be a key determinant ofresource allocation for health,and Rawls’ notion of the obli-gation to maximize the well-being of those worst off.39
Sen noted as a ‘‘particularly se-rious . . . injustice . . . the lackof opportunity that some mayhave to achieve good healthbecause of inadequate socialarrangements. . . .’’40 Sen arguedthat health is a prerequisite forthe capability to function nor-mally in society.31 It is thereforeparticularly unjust that thosewho are socially disadvantagedshould also experience addi-tional obstacles to opportunitybased on having worse health.Ratifying human rights agree-ments obliges governments todirect special effort toward
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 discriminationor marginalization. These categories reflect social advantage or disadvantage when they determinean individual’s or group’s 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 differenceswarranting focused attention. They are a specific subset of health differences of particular relevanceto social justice because they may arise from intentional or unintentional discrimination ormarginalization 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 principleunderlying a commitment to reducing disparities in health and its determinants; health equity issocial justice in health.
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equalizing the rights of vulner-able groups facing more obsta-cles to realizing their rights. Anonexhaustive list of vulnerablegroups is specified in humanrights documents on non-discrimination and equal-ity.32,37,41,42
The resources needed to behealthy (i.e., the determinants ofhealth, including living andworking conditions necessary forhealth, as well as medical care)should be distributed fairly. Todo so requires considering need(along with capacity to benefit16
and efficiency17) rather thanability to pay or influence insociety.17 This principle, alongwith principles cited previously,reflects the ethical notion ofdistributive justice (a just distri-bution of resources needed forhealth) and the human rightsprinciples of nondiscriminationand equality, as well as theright to a standard of living ade-quate for health. Investmentsin medical care intended toreduce disparities must beweighed against other poten-tially more effective invest-ments that address disparitiesin other health determinants.38
Health equity is the value under-lying a commitment to reduce andultimately eliminate health dis-parities. It is explicitly men-tioned in the Healthy People20202 objectives. Health eq-uity means social justice withrespect to health and reflects theethical and human rights con-cerns articulated previously.Health equity means striving toequalize opportunities to behealthy. In accord with theother ethical principles of be-neficence (doing good) andnonmalfeasance (doing noharm), equity requires con-certed effort to achieve morerapid improvements among
those who were worse off tostart, within an overall strategyto improve everyone’s health.Closing health gaps by worsen-ing advantaged groups’ health isnot a way to achieve equity.Reductions in health disparities(by improving the health of thesocially disadvantaged) are themetric by which progress to-ward health equity is measured.
HEALTH DISPARITIES:DEFINITION ANDRATIONALE
We briefly define health dis-parities and health equity (see thebox on the previous page), elabo-rating further and explaining inthis section. We also discuss socialdisadvantage, a key concept forunderstanding disparities and eq-uity (see the box on this page).Health disparities are systematic,plausibly avoidable health differ-ences adversely affecting sociallydisadvantaged groups. Theymay reflect social disadvantage,
although a causal link need not bedemonstrated. Differences amonggroups in their levels of socialadvantage or disadvantage, whichcan be thought of as wheregroups rank in social hierarchies,are indicated by measuresreflecting the extent of wealth,political or economic influence,prestige, respect, or social accep-tance of different populationgroups.
Systematic But Not
Necessarily Causal Links With
Social Disadvantage
As noted by Starfield,45 healthdisparities are systematic, that is,not isolated or exceptional find-ings. Health disparities are sys-tematically linked with social dis-advantage, and may reflect socialdisadvantage, although a causallink does not need to be demon-strated. Whether or not a causallink exists, health disparities ad-versely affect groups who are al-ready disadvantaged socially, put-ting them at further disadvantagewith respect to their health,
thereby making it potentially moredifficult to overcome social disad-vantage. This reinforcement orcompounding of social disadvan-tage is what makes health dispar-ities relevant to social justice evenwhen knowledge of their causa-tion is lacking. It is important todefine health disparities withoutrequiring proof of causality, be-cause there are important healthdisparities for which the causeshave not been established, butwhich deserve high priority basedon social justice concerns. Forexample, the large Black—Whitedisparity in low birth weightand premature birth strongly pre-dicts disparities in infant mortalityand child development, andlikely in adult chronic disease.46
Although the causes of racialdisparity in birth outcomes arenot established,46 credible scientificsources have identified biologi-cal mechanisms that plausiblycontribute to the disparities,46—50
which reflect phenomena shapedby social contexts and thus are, atleast 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. Socialdisadvantage is reflected, for example, by low levels of wealth, income, education, or occupationalrank, or by less representation at high levels of political office. Criteria for social disadvantage canbe absolute (e.g., the federal poverty threshold in the United States is based on an estimate of theincome 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 number of European countries are defined in relation to the medianincome, e.g., less than 50% of the median income).44
Not all members of a disadvantaged group will necessarily be (uniformly) disadvantaged, and not allsocially disadvantaged groups will necessarily manifest measurable adverse health consequences.The extent (whether in a single or multiple domains), depth (severity), and duration (e.g., acrossmultiple generations) of disadvantage matter. Social disadvantage is different from unavoidablephysical disadvantage due to, for example, an unavoidable physical disability. However, whendisabled persons are put at an unnecessary disadvantage in society due to lack of feasiblesupports (e.g., accessible public buildings and transportation) or to discrimination against them inhiring for work that they could perform, this would constitute social disadvantage,reflecting discriminatory treatment, whether intentional or unintentional.
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Plausibly Avoidable
Differences in Health Given
Sufficient Political Will
It must be plausible, but not
necessarily proven, that policies
could reduce the disparities, in-
cluding not only policies affecting
medical care but also social poli-
cies addressing important non-
medical determinants of health
and health disparities, such as a
decent standard of living; a level of
schooling permitting full social
participation, including participa-
tion in the workforce and political
activities; health-promoting living
and working conditions, includ-
ing both social and physical envi-
ronments; and respect and social
acceptance.23,51 This criterion
addresses the issue of avoidability,
which is central to Whitehead’s
definition of health inequalities; it
strives for more specificity about
avoidability and to clarify the bur-
den of proof regarding causality.21
Avoidability can be highly sub-jective. For example, one personmay believe that ill health causedby poverty is avoidable; another,however, may believe that bothpoverty and ill health among thepoor are inevitable; hence, thesedisparities are unavoidable. Ac-cording to the proposed definition,the criterion is whether the givencondition is theoretically avoidable,based on current knowledge ofplausible causal pathways and bi-ological mechanisms, and assumingthe existence of sufficient politicalwill. The more solid the knowl-edge, the more reasonable andpolitically viable it will be to investresources in interventions; feasi-bility, costs, and potentially harm-ful unintended consequencesmust be considered. Without firmknowledge to guide specific inter-ventions, pursuing health equitywould require supporting researchon how to intervene effectively
and efficiently to reduce importantdisparities.
Worse Health Among Socially
Disadvantaged Groups
Socially disadvantaged groupsare defined a priori, according tocriteria consistent with humanrights principles regarding non-discrimination and equality.Health disparities and equityshould be central considerationsfor public policy relevant tohealth, but they are not the onlyconsiderations. Other legitimateconsiderations include the mag-nitude of impact and proportionof the population affected, aswell as efficiency in the use ofresources. If a more sociallyadvantaged group happens tofare worse on a particular healthindicator, this may be a very im-portant issue that public healthor other sectors should energeti-cally address; but it is not part ofa ‘‘health disparities’’ agenda,which focuses on improving thehealth of socially disadvantagedgroups.
The Need to Reduce
Disparities in the
Determinants of Health
Health determinants includenot only medical care but also thequality of the social and physicalconditions in which people live,work, learn, and play.23,51,52
Evidence of disparities in healthdeterminants is thus relevant toassessing disparities in health.Society will generally be moremotivated to address health dif-ferences that appear to resultfrom modifiable circumstancesover which individuals may havelittle control21,53; for example,the quality of local schools, ex-posure to pollution or crime,or absence of stores selling nu-tritious food in one’s neighbor-hood.
Disadvantaged Groups Are
Not Necessarily Uniformly
Disadvantaged
Internationally recognized hu-man rights documents provideguidance on which groups aredisadvantaged. Although healthdisparities are systematic, a so-cially disadvantaged group willnot necessarily fare worse on allhealth indicators, and might farebetter on some. For example, non-Hispanic European American orWhite (hereafter ‘‘White’’) womenover age 40 have higher incidenceof breast cancer than non-His-panic African American or Black(hereafter ‘‘Black’’) women,54 andbabies born to Hispanic immigrantwomen often have more favorablebirth weights than those born tonon-Hispanic Whites.55 Neither ofthese differences––although bothdeserve public health attention––would be a health disparity by theproposed definition. Regardlessof this type of exception in relationto a health outcome, Whites asa group are more socially advan-taged than Blacks and Hispanics,as data on income, wealth, educa-tion, occupations, and politicaloffice have documented.56—58
Furthermore, on most health indi-cators, including breast cancer mor-tality, White women are healthierthan Black women.59 Similarly,higher rates of a preventableillness in1of 2 affluent geographicregions would warrant publichealth action, but not as a healthdisparities concern.
The fact that not all membersof a disadvantaged group (e.g.,Blacks) appear to be severely dis-advantaged (e.g., we have a BlackUnited States President, andsome Blacks are highly educated,in high professional positions,and/or wealthy) does not contra-dict considering that group asgenerally disadvantaged. The
issue is whether the group has beenon the whole more disadvantagedthan Whites. Ample evidence hasdocumented a longstanding patternof less wealth,60,61 lower incomes,lower educational attainment, andunder-representation in positionsof high occupational rank56 andfinancial and political power62
among Blacks as a group com-pared with Whites. Despite an endto legal racial segregation decadesago, racial residential segregationpersists and with it, de facto edu-cational segregation, condemningmany Black children to poorquality schools. This reduces theirchances of obtaining good jobswith adequate income as adults,perpetuating social disadvantageacross generations.63,64
Similarly, although manyUnited States women are affluentand some now hold high profes-sional and political offices, asa group, they are more likelythan men to be poor,65 to earnless at a given educational level,66
and to be underrepresented inhigh political office.67 Humanrights documents on nondiscrim-ination explicitly name women asa vulnerable group warrantingspecial protection from discrimi-nation. Patterns suggesting clini-cally unjustified underreceipt ofcertain cardiac treatments bywomen compared with men68
would reflect a gender disparityin a determinant of health(medical care, in this instance).Shorter life expectancy amongmen in general, if likely avoid-able, would clearly be an issue ofpublic health importance basedon the magnitude of potentialpopulation impact. However,men as a group have morewealth, influence, and prestige, sothis difference would not bea social injustice and, therefore,not a health disparity or equityissue.
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Health Disparities as the
Metric to Assess Progress
Toward Health Equity
The stated criteria permit theassessment of measurable prog-ress toward greater health equity.Systematic associations with socialdisadvantage can be identified byobserving a repeated pattern ofcorrelations between measures ofsocial disadvantage and a healthoutcome. Social advantage anddisadvantage can be measured bycomparing populations on factorssuch as levels of wealth, income,educational attainment, or occu-pational rank, for example (see thebox on page S151). Demonstratingthat a given disparity is plausiblyavoidable and can be reduced bypolicies requires being able to de-scribe, at least in general terms, 1or more potential causal pathwaysthat are consistent with currentscientific knowledge; it does notrequire definitively establishingeither the causation of the dispar-ity or proving the effectiveness ofexisting interventions to reduceit. Guidelines for measuring healthdisparities are available.9,69—73
Increasingly, the term ‘‘healthinequity’’21,74,75––the opposite ofhealth equity––is being used in-stead of ‘‘health disparity’’ to cap-ture explicitly the moral dimensionand differentiate health differencesthought to reflect injustice fromhealth differences in general. Ex-amples of health differences thatwould not be considered healthdisparities according to our defi-nitions (see the box on page S150)include: elderly adults generallyhaving worse health than noneld-erly adults; skiers being at higherrisk of long-bone fractures thannonskiers; and men not havingobstetric problems, whereaswomen do. Both ‘‘health disparity’’and ‘‘health inequity’’ have theirplace in the public health lexicon.
Health inequity, however, is aforceful term tending to implya strong judgment about causality,which may be difficult to support inmany cases that nevertheless de-serve attention as health disparities(i.e., health differences adverselyaffecting socially disadvantagedgroups) regardless of their causa-tion. As with health equity, mea-suring health inequity relies onhealth disparities as the metric.
Health Disparity: Not Just
a Health Difference
Interpreting the term ‘‘healthdisparities’’ as any health differ-ences among any populationgroup, as has been done by somefederal agencies, encompasses theentire domain of epidemiology,which is the study of the distribu-tion of diseases and risk factorsacross different populations. Wehave argued that the term healthdisparities should be used advis-edly, in the spirit of the movementfor social justice from which theterm emerged, to refer to a partic-ular subset of differences in healththat meet well-specified criteriaof specific relevance to social jus-tice. The definitions proposed herewere designed to clarify the con-cepts of health disparities andhealth equity in ways that couldstand up to rigorous conceptualscrutiny as a basis for guidingpolicy and practice and ensuringaccountability, which requiresclear criteria for measure-ment.9,69,70 To achieve the de-sired rigor, the full versions of theproposed definitions are complexand technical and will not be suit-able for all audiences; for manyaudiences, it may be most appro-priate to define health disparitiessimply as worse health amongsocially disadvantaged groupsand then elaborate as necessary,drawing on the more comprehen-sive form of the definitions.
Limitations
These definitions do not pro-vide numerical cutoffs for deter-mining disadvantage. Nor do theyremove completely the need toexercise judgment based on valuesthat are likely to vary across in-dividuals and societies. It isdifficult to imagine reasonabledefinitions of these concepts,however, that would provide rigidcutoffs, would completely pre-clude the exercise of judgment,and would leave no room forcontention. The proposed defini-tions do not clarify whether thereference group for making eq-uity/disparities comparisonsshould be the most advantagedgroup in one’s country or in theworld; using one’s country as thereference point may ignore thebetter health achieved by advan-taged populations in other parts ofthe world.
Challenges Addressed
The definitions address majorchallenges, such as identifying thesocial groups to be compared andspecifying the general criteria forappropriate reference groups forthese comparisons.18 These chal-lenges have arisen when consid-ering health disparity or equityissues, with serious implicationsfor resource allocation. Thesedefinitions remove the need toestablish the causality and avoid-ability of each health difference forit to qualify as a health disparityworthy of special attention. To ad-dress the difficult issue of causality,our definitions acknowledge thata health disparity may or may notarise from social disadvantage, butit must adversely affect members ofsocially disadvantaged groups; thiscan be assessed using epidemiologicdata revealing repeated and perva-sive associations between healthindicators and measures of social
advantage. The causes need not beknown definitively, if it is biologi-cally plausible that the differencecould be reduced by policies.These definitions also ground theconcepts of health disparities andhealth equity in internationallyrecognized principles from thefields of ethics and human rights,giving them universality and du-rability. Although human rightsare often honored more in thebreach than in the observance,they are a powerful resource inthat they represent a global con-sensus on values. This consensuscan be an important point of ref-erence in national and local de-bates on policies and practice inthe United States. It would benaı̈ve to think that achieving con-sensus on a definition would ob-viate the need for constant vigi-lance to ensure that the agenda forresearch and action on health dis-parities remains on track and trueto the essence of the definition;however, having a clear definitionis crucial.
The Issue is Justice
Could this approach––puttinghealth disparities within thebroader context of ethics and hu-man rights––jeopardize the limitedresources allocated to specificallyaddress racial/ethnic disparities,by spreading these resources morethinly among other disadvantagedgroups? Would broadening thedefinition make the concept tooabstract and therefore less com-pelling to the public and policy-makers? We concluded that thestruggle for racial justice, in whichefforts to eliminate racial/ethnicdisparities in health are crucial,has far more to gain than to losefrom making these principles ex-plicit. The relevant ethical andhuman rights principles supportprioritizing attention to those fac-ing the greatest obstacles, and
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ample evidence has documentedthe multiple and often crushingobstacles faced by members ofdisadvantaged racial/ethnicgroups in the United States, insome cases for centuries. Theseprinciples can protect initiativesto address racial/ethnic as well asother disparities in health froma range of potential challengesthat constitute real threats.
Previous official approaches todefining health disparities in theUnited States have avoided beingexplicit about values and princi-ples, perhaps for fear of stirringpolitical opposition, because ofgenuine differences in values orbecause of the prevailing ethosthat enjoins researchers to avoidthe realm of values that mightcompromise the integrity of theirscience. Scientists, like all others,should be guided by ethical andhuman rights values. The firstdecade of the 21st century hasended with little if any evidenceof progress toward eliminatinghealth disparities by race or so-cioeconomic status.22 It is time tobe explicit that the heart of acommitment to addressing healthdisparities is a commitment toachieving a more just society. j
About the AuthorsPaula A. Braveman is with the Universityof California, San Francisco. ShirikiKumanyika is with University ofPennsylvania School of Medicine,Philadelphia. Jonathan Fielding is with theUniversity of California, Los Angeles,School of Public Health. Thomas LaVeist iswith Johns Hopkins Bloomberg School ofPublic Health, Baltimore, MD. Luisa N.Borrell is with Lehman College, CityUniversity of New York, New York. RonManderscheid is with the NationalAssociation of County Behavioral Healthand Developmental Disability Directors,Washington, DC. Adewale Troutman iswith the Louisville Metro Department ofPublic Health and Wellness, Louisville, KY.
Correspondence should be sent to Paula A.Braveman, MD, MPH, Director/Professor,Center on Social Disparities in Health,University of California, San Francisco,
3333 California St., Suite 365, San Francisco,CA 94118 (e-mail: Braveman@fcm.ucsf.edu).Reprints can be ordered at http://www.ajph.org by clicking the ‘‘Reprints/Eprints’’ link.
This article was accepted November 1,2010.
ContributorsAll the authors participated conceptuallyin developing the recommendations tothe Secretary’s Advisory Committee(SAC) on Healthy People 2020, whichwere the starting point for this article, andall authors contributed ideas, revieweddrafts, and made comments that shapedthis article in important ways. P. A.Braveman conceived the initial idea forthe article, wrote initial drafts, and wrotemost revisions for coauthors’ review,based on their comments. S. Kumanyikaalso played a major role in writing the textand a lead role in responding to externalreviewer comments. J. Fielding, T. LaVeist,L.N. Borrell, R. Manderscheid, andA.Troutman also contributed conceptuallyand participated in substantive revisionsthroughout the process.
AcknowledgmentsWe wish to thank Karen Simpkins, MLS,and Colleen J. Barclay, MPH, for theirassistance with research. Written permis-sion has been obtained from all personsnamed here. The authors take full re-sponsibility for the contents of this paperas individuals. This article is not an officialreport from the SAC or from the sub-committee to the SAC.
Note. The research presented hereneither has been published nor is beingconsidered for publication elsewhere,and all research for this manuscript wasconducted in accord with prevailingethical principles. We have no affilia-tions with or involvement in any orga-nization or entity with a direct financialinterest in the subject matter or materialsdiscussed in this manuscript. None of theauthors received compensation for thiswork. The authors take full responsibil-ity for the material.
Human Participant ProtectionNo institutional review board approvalwas required.
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