The Health Equation: Equity, Justice, and Global Health

(Image credit: The Edinburgh Blog www.theedinburghblog.co.uk)

Inequities: they are everywhere, aren't they?

The world is not a fair place. Anybody harbouring any illusions on that account should have a quick look at sites like Gapminder, which aims at showcasing the world's inequalities, or online database NationMaster, which consolidates and presents numerous (inter)national statistics. An insightful example is NationMaster's ranking of life expectancy at birth, which goes from 84 years for Macau, to 32 years for Swaziland. However, are these inequalities also inequities, and if so, what are the global health dimensions of these inequities? This article is the first in a short series that explores these two questions, as well as the question of what global health professionals can and should do about inequities.

What is an inequity?

From a global health perspective, the very least one can say is that there seems to be a clear link between a country's poverty and its health; e.g. Luxembourg, with the highest GDP per capita in the world, has a life expectancy at birth of 79, whereas the average Burundian, living in the country with the lowest GDP per capita, can expect to live 52 years when born. However, is this inequity, or ‘just' inequality? To answer this, we would first need a definition of inequity.

There are many different definitions of inequity. For example, Braveman and Gruskin see inequities as inequalities that are systematic between groups. A big problem with this definition is that it would lead to an endless stream of perceived inequities, as almost any inequality has some systematic element in it. A much better definition, hailing back to a 1990s paper by Whitehead and Dahlgren, suggests that inequalities are inequitable when they are avoidable, unnecessary, and unfair. This states much more clearly what exactly the injustice inherent in inequities is: they are not just unpleasant facts, but the result of our actions (or lack thereof). It relates much more closely to our instinctive understanding of inequities: an inequality is only an inequity if somebody, somewhere could have prevented or remedied it, the inequality is not a necessary by-product of a policy that aims to achieve a higher goal, and if we feel that the inequality is unfair to its victims.

This would imply that, by itself, the difference in life expectancy between Luxemburg and Burundi is not an inequity, as we have no realistic means to make Burundi as rich as Luxemburg (but it will not come as a surprise that I will qualify this considerably in the next article in the series). Neither is the difference in life expectancy between a person with a normal, active lifestyle and a professional daredevil an inequity, as it would not satisfy the fairness test: most of us would feel that the daredevil takes those risks purposefully and well-aware, and that he should reap the drawbacks as well as the benefits.