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Journal of Epidemiology and Community Health logoLink to Journal of Epidemiology and Community Health
. 2000 Dec;54(12):923–929. doi: 10.1136/jech.54.12.923

Why reduce health inequalities?

A Woodward 1, I Kawachi 1
PMCID: PMC1731601  PMID: 11076989

Abstract

It is well known that social, cultural and economic factors cause substantial inequalities in health. Should we strive to achieve a more even share of good health, beyond improving the average health status of the population? We examine four arguments for the reduction of health inequalities.
1 Inequalities are unfair.
Inequalities in health are undesirable to the extent that they are unfair, or unjust. Distinguishing between health inequalities and health inequities can be contentious. Our view is that inequalities become "unfair" when poor health is itself the consequence of an unjust distribution of the underlying social determinants of health (for example, unequal opportunities in education or employment).
2 Inequalities affect everyone.
Conditions that lead to marked health disparities are detrimental to all members of society. Some types of health inequalities have obvious spillover effects on the rest of society, for example, the spread of infectious diseases, the consequences of alcohol and drug misuse, or the occurrence of violence and crime.
3 Inequalities are avoidable.
Disparities in health are avoidable to the extent that they stem from identifiable policy options exercised by governments, such as tax policy, regulation of business and labour, welfare benefits and health care funding. It follows that health inequalities are, in principle, amenable to policy interventions. A government that cares about improving the health of the population ought therefore to incorporate considerations of the health impact of alternative options in its policy setting process.
3 Interventions to reduce health inequalities are cost effective.
Public health programmes that reduce health inequalities can also be cost effective. The case can be made to give priority to such programmes (for example, improving access to cervical cancer screening in low income women) on efficiency grounds. On the other hand, few programmes designed to reduce health inequalities have been formally evaluated using cost effectiveness analysis.
We conclude that fairness is likely to be the most influential argument in favour of acting to reduce disparities in health, but the concept of equity is contested and susceptible to different interpretations. There is persuasive evidence for some outcomes that reducing inequalities will diminish "spill over" effects on the health of society at large. In principle, you would expect that differences in health status that are not biologically determined are avoidable. However, the mechanisms giving rise to inequalities are still imperfectly understood, and evidence remains to be gathered on the effectiveness of interventions to reduce such inequalities.


Keywords: health inequalities; equity; interventions; social determinants of health

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Selected References

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  1. Adler N. E., Boyce W. T., Chesney M. A., Folkman S., Syme S. L. Socioeconomic inequalities in health. No easy solution. JAMA. 1993 Jun 23;269(24):3140–3145. [PubMed] [Google Scholar]
  2. Brook R. H., Ware J. E., Jr, Rogers W. H., Keeler E. B., Davies A. R., Donald C. A., Goldberg G. A., Lohr K. N., Masthay P. C., Newhouse J. P. Does free care improve adults' health? Results from a randomized controlled trial. N Engl J Med. 1983 Dec 8;309(23):1426–1434. doi: 10.1056/NEJM198312083092305. [DOI] [PubMed] [Google Scholar]
  3. Carmichael C. L., Rugg-Gunn A. J., Ferrell R. S. The relationship between fluoridation, social class and caries experience in 5-year-old children in Newcastle and Northumberland in 1987. Br Dent J. 1989 Jul 22;167(2):57–61. doi: 10.1038/sj.bdj.4806919. [DOI] [PubMed] [Google Scholar]
  4. Charlton B. G. Is inequality bad for the national health? Lancet. 1994 Jan 22;343(8891):221–222. doi: 10.1016/s0140-6736(94)90996-2. [DOI] [PubMed] [Google Scholar]
  5. Colditz G. A., Hoaglin D. C., Berkey C. S. Cancer incidence and mortality: the priority of screening frequency and population coverage. Milbank Q. 1997;75(2):147–173. doi: 10.1111/1468-0009.00050. [DOI] [PMC free article] [PubMed] [Google Scholar]
  6. Daniels Norman, Kennedy Bruce P., Kawachi Ichiro. Why justice is good for our health: the social determinants of health inequalities. Daedalus. 1999 Fall;128(4):215–251. [PubMed] [Google Scholar]
  7. Kawachi I., Kennedy B. P. Health and social cohesion: why care about income inequality? BMJ. 1997 Apr 5;314(7086):1037–1040. doi: 10.1136/bmj.314.7086.1037. [DOI] [PMC free article] [PubMed] [Google Scholar]
  8. Kawachi I., Marshall S., Pearce N. Social class inequalities in the decline of coronary heart disease among New Zealand men, 1975-1977 to 1985-1987. Int J Epidemiol. 1991 Jun;20(2):393–398. doi: 10.1093/ije/20.2.393. [DOI] [PubMed] [Google Scholar]
  9. Kennedy B. P., Kawachi I., Prothrow-Stith D. Income distribution and mortality: cross sectional ecological study of the Robin Hood index in the United States. BMJ. 1996 Apr 20;312(7037):1004–1007. doi: 10.1136/bmj.312.7037.1004. [DOI] [PMC free article] [PubMed] [Google Scholar]
  10. Link B. G., Phelan J. C. Understanding sociodemographic differences in health--the role of fundamental social causes. Am J Public Health. 1996 Apr;86(4):471–473. doi: 10.2105/ajph.86.4.471. [DOI] [PMC free article] [PubMed] [Google Scholar]
  11. Mackenbach J. P., Gunning-Schepers L. J. How should interventions to reduce inequalities in health be evaluated? J Epidemiol Community Health. 1997 Aug;51(4):359–364. doi: 10.1136/jech.51.4.359. [DOI] [PMC free article] [PubMed] [Google Scholar]
  12. Marchand S., Wikler D., Landesman B. Class, health and justice. Milbank Q. 1998;76(3):449-67, 305-6. doi: 10.1111/1468-0009.00098. [DOI] [PMC free article] [PubMed] [Google Scholar]
  13. Marmot M. G., McDowall M. E. Mortality decline and widening social inequalities. Lancet. 1986 Aug 2;2(8501):274–276. doi: 10.1016/s0140-6736(86)92085-4. [DOI] [PubMed] [Google Scholar]
  14. Marmot M. G., Smith G. D. Why are the Japanese living longer? BMJ. 1989 Dec 23;299(6715):1547–1551. doi: 10.1136/bmj.299.6715.1547. [DOI] [PMC free article] [PubMed] [Google Scholar]
  15. Marshall S. W., Kawachi I., Pearce N., Borman B. Social class differences in mortality from diseases amenable to medical intervention in New Zealand. Int J Epidemiol. 1993 Apr;22(2):255–261. doi: 10.1093/ije/22.2.255. [DOI] [PubMed] [Google Scholar]
  16. Martikainen P., Valkonen T. Inequalities in health. Policies to reduce income inequalities are unlikely to eradicate inequalities in mortality. BMJ. 1999 Jul 31;319(7205):319–319. [PMC free article] [PubMed] [Google Scholar]
  17. McMichael A. J. The role of epidemiologists in eradicability of poverty. Lancet. 1998 Nov 14;352(9140):1627–1627. doi: 10.1016/s0140-6736(05)61073-2. [DOI] [PubMed] [Google Scholar]
  18. Pappas G., Queen S., Hadden W., Fisher G. The increasing disparity in mortality between socioeconomic groups in the United States, 1960 and 1986. N Engl J Med. 1993 Jul 8;329(2):103–109. doi: 10.1056/NEJM199307083290207. [DOI] [PubMed] [Google Scholar]
  19. Phillimore P., Beattie A., Townsend P. Widening inequality of health in northern England, 1981-91. BMJ. 1994 Apr 30;308(6937):1125–1128. doi: 10.1136/bmj.308.6937.1125. [DOI] [PMC free article] [PubMed] [Google Scholar]
  20. Reading R., Colver A., Openshaw S., Jarvis S. Do interventions that improve immunisation uptake also reduce social inequalities in uptake? BMJ. 1994 Apr 30;308(6937):1142–1144. doi: 10.1136/bmj.308.6937.1142. [DOI] [PMC free article] [PubMed] [Google Scholar]
  21. Riley J. C., Lennon M. A., Ellwood R. P. The effect of water fluoridation and social inequalities on dental caries in 5-year-old children. Int J Epidemiol. 1999 Apr;28(2):300–305. doi: 10.1093/ije/28.2.300. [DOI] [PubMed] [Google Scholar]
  22. Rose G. Sick individuals and sick populations. Int J Epidemiol. 1985 Mar;14(1):32–38. doi: 10.1093/ije/14.1.32. [DOI] [PubMed] [Google Scholar]
  23. Rothman K. J., Adami H. O., Trichopoulos D. Should the mission of epidemiology include the eradication of poverty? Lancet. 1998 Sep 5;352(9130):810–813. doi: 10.1016/s0140-6736(98)01327-0. [DOI] [PubMed] [Google Scholar]
  24. Townsend J., Roderick P., Cooper J. Cigarette smoking by socioeconomic group, sex, and age: effects of price, income, and health publicity. BMJ. 1994 Oct 8;309(6959):923–927. doi: 10.1136/bmj.309.6959.923. [DOI] [PMC free article] [PubMed] [Google Scholar]
  25. Treasure E. T., Dever J. G. The prevalence of caries in 5-year-old children living in fluoridated and non-fluoridated communities in New Zealand. N Z Dent J. 1992 Jan;88(391):9–13. [PubMed] [Google Scholar]
  26. Wallace R., Wallace D. Socioeconomic determinants of health: community marginalisation and the diffusion of disease and disorder in the United States. BMJ. 1997 May 3;314(7090):1341–1345. doi: 10.1136/bmj.314.7090.1341. [DOI] [PMC free article] [PubMed] [Google Scholar]
  27. Wilson M., Daly M. Life expectancy, economic inequality, homicide, and reproductive timing in Chicago neighbourhoods. BMJ. 1997 Apr 26;314(7089):1271–1274. doi: 10.1136/bmj.314.7089.1271. [DOI] [PMC free article] [PubMed] [Google Scholar]
  28. Woolhandler S., Himmelstein D. U. Free care: a quantitative analysis of health and cost effects of a national health program for the United States. Int J Health Serv. 1988;18(3):393–399. doi: 10.2190/78J9-BWXL-Y6AL-45RA. [DOI] [PubMed] [Google Scholar]

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