World Health Report 2000: how it removes equity from the agenda for public health monitoring and policy Commentary: comprehensive approaches are needed for full understanding

Abstract

Health and social inequalitiesWithout studying the report's technical references,2–4 most readers will assume that health inequalities refer to social inequalities in health. Social inequalities in health are health disparities between population groups defined by social characteristics such as wealth, education, occupation, racial or ethnic group, sex, rural or urban residence, and social conditions of the places where people live and work. These social characteristics are selected for defining population groups and comparing how health and health care vary across the different groups because of their strong and ubiquitous associations with both underlying social advantage and health. The report's official press statements reinforce this assumption.5However, earlier publications by the report's authors stated that their intention was not to measure social inequalities in health but rather the magnitude of differences in health among all individuals in a society, without categorising them into social groups. The intention was to describe the ungrouped individuals solely by how sick or well they are, without regard for other characteristics such as poverty or affluence. Thus the report's measure may reflect the differences in health between the sickest and healthiest people in a country but not between the poorest and richest. Relevant technical arguments have been discussed elsewhere. 2 6What is inequality?Braveman et al believe that health inequalities correlated with factors other than income, social class, and race are not morally important. Citing themselves, they go further and propose that health inequality is defined as the subset of health inequalities correlated with these socioeconomic factors. For a child with an increased risk of death because she lives in a community with a poor immunisation programme and a high prevalence of HIV, it is no solace to know that her risk of death is uncorrelated with income, social class, or race. To most of us, inequality is the state of being unequal. Health inequalities exist when individuals' risks of death and poor health are unequal. The WHO argues that health inequalities should be measured comprehensively. Health scientists can then help determine the causes of inequality and the policies and programmes that can be used to tackle these causes.Other disciplines such as economics tend to use comprehensive approaches to measuring inequality rather than selective approaches. When economists study income inequality, they do not simply report differences in average income for social class or race groups. Rather, they measure the entire distribution of income across individuals or households and summarise that distribution with measures such as the Gini coefficient. It then becomes a scientific challenge to determine how much is explained by social class or race.For health, the WHO has adopted the same approach. Firstly, measure the full extent of health inequality in a population. Secondly, use the tools of science to understand what factors explain this inequality. Thirdly, formulate policies that can act on these causes of inequality. Fourthly, monitor and evaluate the impact of these policies on inequality. With this comprehensive approach, an evidence base can be constructed on the causes of health inequality and the policy options available to tackle it.