The hidden inequity in health care

Inequity is the presence of systematic and potentially remediable differences among population groups defined socially, economically, or geographically [1,2]. It is not the same as inequality, which is a much broader term, generally used in the human rights field to describe differences among individuals, some of which are not remediable (at least with current knowledge). Some languages do not make a distinction between the two terms, which may lead to confusion and a need to clarify exact meaning in different contexts. Some people use the term “unfairness” to define inequity, but unfairness is not measurable and therefore not a useful term for policy or evaluation. Inequity can be horizontal or vertical. Horizontal inequity indicates that people with the same needs do not have access to the same resources. Vertical inequity exists when people with greater needs are not provided with greater resources. In population surveys, similar use of services across population groups signifies inequity, because different population subgroups have different needs, some more than others. What is generally considered equity (equal use across population subgroups) is, in fact, inequity. Most industrialized countries have achieved both horizontal and vertical equity in the use of primary care services, meaning that people with greater health needs receive more primary care services. Although some countries have achieved horizontal equity in use of specialist services, very few have achieved vertical equity because socially-deprived populations have less access to specialist services than their needs require. There are no statistics on inequity in health in different countries. All standard health statistics describe average or “mean” health in the population life expectancy, infant mortality, death rates from various diseases, and the like. Health indicators that are used to describe various aspects of population health and the impact of services on them are also useful for assessing equity in health. Producing them only requires stratifying the population into the social, economic, or geographic indicator and determining if there are differences in the rates of the indicator across the strata. As equity is an international priority, countries should be collecting data on inequities among groups in the population. Although equity in use of services is a worldwide imperative, an even more serious challenge is posed by the way of thinking about illness and its impact. The very underpinnings of modern-day health services are inequitable. Western health systems are dominated by a paradigm of illness that considers “diseases” to be the basic element of pathology [3]. Beginning with the anatomist Vesalius in the 17 century, disease came to be thought of in terms of abnormalities in body organs, with each abnormality adding, in linear fashion, to the extent of illness. Medicine is still practiced this way, with each disease requiring special knowledge and special expertise for management, and adherence to each disease guideline adding linearly to the quality of care provided. In this outdated scheme, there is no room for recognizing that diseases are not distinct biological entities that exist alone and apart from the person. A century ago, thoughtful clinicians (such as Sir William Osler) recognized that it is more important to know “what sort of patient has a disease than to know what sort of disease a patient has” [4]. The only change that might be made to this dictum a century later is to substitute diseases, risk factors, and adverse effects for “disease”. A “whole-patient oriented” view of disease is more accurate than a disease oriented view. It is also more equitable. Diseases are more likely to occur and to be more serious in socially disadvantaged people [2,5]. This greater likelihood of occurrence, severity, and adverse effects is compounded even further by multiple illnesses, multiple serious illnesses, and greater likelihood of adverse events from incompatible interventions. Only a person-focused (rather than a disease-focused) view of morbidity, in which multiple illnesses interact in myriad ways, can accurately depict the much greater impact of illness among socially disadvantaged people and the Correspondence: [email protected] University Distinguished Professor, Department of Health Policy and Management, Johns Hopkins University, 624 North Broadway, room 452, Baltimore, MD 21205, USA Starfield International Journal for Equity in Health 2011, 10:15 http://www.equityhealthj.com/content/10/1/15