Health Disparities and Health Equity: The Issue Is Justice

Published Ahead of Print on May 6, 2011, as 10.2105/AJPH.2010.300062
The latest version is at http://ajph.aphapublications.org/cgi/doi/10.2105/AJPH.2010.300062
ANALYTIC ESSAY FORUM

Health Disparities and Health Equity: The Issue Is Justice
Eliminating health dis- Paula A. Braveman, MD, MPH, Shiriki Kumanyika, PhD, MPH, Jonathan Fielding, MD, MPH, MA, MBA,
parities is a Healthy Peo- Thomas LaVeist, PhD, Luisa N. Borrell, DDS, PhD, Ron Manderscheid, PhD,
ple goal. Given the diverse and Adewale Troutman, MD, MPH, MA
and sometimes broad defi-
nitions of health disparities
commonly used, a sub- ONE OF 2 OVERARCHING cultural, and technical perspec- wording. Clarifying these concepts
committee convened by the goals of Healthy People 20101 was tives may generate different defi- will enable medical and public
Secretary’s Advisory Com- ‘‘to eliminate health disparities nitions of health disparities or in- health practitioners and leaders to
mittee for Healthy People among different segments of the equalities (the most comparable be more effective in reducing dis-
2020 proposed an opera- population.’’ A similar goal to term outside the United States).9---21 parities in medical care and in
tional definition for use in
‘‘achieve health equity and elimi- For example, in the United King- advocating for social policies (e.g.,
developing objectives and
nate health disparities’’ was pro- dom, Whitehead defined health in child care, education, housing,
targets, determining re-
posed by the Health and Human inequalities as differences that are labor, and urban planning) that
source allocation priorities,
and assessing progress. Services Secretary’s Advisory unnecessary, avoidable, and un- can have major impacts on popu-
Based on that subcom- Committee (SAC) for Healthy Peo- fair.21 This definition is widely lation health.27
mittee’s work, we propose ple 2020.2 Healthy People 2010 used internationally, where
that health disparities are noted that health disparities ‘‘in- ‘‘health inequalities’’ are assumed UNDERLYING VALUES AND
systematic, plausibly avoid- clude differences that occur by to be socioeconomic differences PRINCIPLES
able health differences ad- gender, race or ethnicity, educa- unless otherwise specified; in the
versely affecting socially tion or income, disability, living in United States, however, ‘‘health The concepts of health dispar-
disadvantaged groups; they rural localities, or sexual orienta- disparities’’ more often refer to ities and health equity are rooted
may reflect social disad-
tion.’’1 However, the rationale for racial or ethnic differences. in deeply held American social
vantage, but causality need
identifying disparities in relation Effective public policies require values and pragmatic consider-
not be established. This def-
to these particular population clear and contextually relevant ations, as well as in internationally
inition, grounded in ethical
and human rights princi- groups was not articulated. The operational definitions to support recognized ethical and human
ples, focuses on the subset National Institutes of Health de- the development of objectives and rights principles.9 Drawing on
of health differences re- fined health disparities as ‘‘differ- specific targets, determine priori- ethical and human rights concepts,
flecting social injustice, ences in the incidence, prevalence, ties for use of limited resources, key principles underlying the
distinguishing health dis- mortality, and burden of diseases and assess progress. The need for concepts of health disparities and
parities from other health and other adverse health condi- clear definitions is particularly health equity include the following:
differences also warranting tions that exist among specific compelling given the lack of prog-
concerted attention, and population groups in the United ress toward reducing racial/ethnic All people should be valued
from health differences in
States’’3,4; several other federal and socioeconomic disparities in equally. This concept was artic-
general.
agencies have similarly broad medical care22 and health.23---25 ulated by Jones et al.28 as foun-
We explain the definition,
definitions.5 The lack of explicit Recognizing the practical implica- dational to the concept of eq-
its underlying concepts, the
challenges it addresses, and criteria for identifying disparities tions of lack of clarity on this uity. Equal worth of all human
the rationale for applying it to in Healthy People 20101 and the critical issue, the SAC convened beings is at the core of the
United States public health relatively nonspecific definitions a subcommittee to define ‘‘health human rights principle that all
policy. (Am J Public Health. of disparities used by federal disparity’’ and ‘‘health equity’’ for human beings equally possess
Published online ahead of agencies3,4 leave considerable use in Healthy People 2020.2 The certain rights.29,30
print May 5, 2011: e1–e7. room for ambiguity as to what subcommittee members, including Health has a particular value for
doi:10.2105/AJPH.2010. other groups might also be rele- both SAC members and external individuals because it is essential
300062) vant. experts, wrote this paper to elab- to an individual’s well-being
Furthermore, there has been orate on the definitions and ex- and ability to participate fully in
controversy as to whether defini- plain their rationale.2,26 These defi- the workforce and a democratic
tions of health disparities should nitions (see the box on the next society. Ill health means potential
imply injustice or simply reflect page) and the rationale presented suffering, disability, and/or loss
differences in health outcomes are substantively consistent with of life, threatens one’s ability to
that might apply to any United those adopted by the SAC and re- earn a living, and is an obstacle
States population segment.6---8 Dif- cently published in Healthy People to fully expressing one’s views
ferent ethical, philosophical, legal, 2020,2 but reflect some changes in and engaging in the political

Published online ahead of print May 5, 2011 | American Journal of Public Health Braveman et al. | Peer Reviewed | Analytic Essay Forum | e1
Copyright 2011 by the American Public Health Association


process. The Nobel Laureate
economist Amartya Sen31 Health Disparities and Health Equity
viewed health as a fundamental Health disparities are health differences that adversely affect socially disadvantaged groups.
capability required to function Health disparities are systematic, plausibly avoidable health differences according to race/ethnicity,
in society; similarly, ill health skin color, religion, or nationality; socioeconomic resources or position (reflected by, e.g., income,
can be a barrier to fully re- wealth, education, or occupation); gender, sexual orientation, gender identity; age, geography,
disability, illness, political or other affiliation; or other characteristics associated with discrimination
alizing one’s human rights.
or marginalization. These categories reflect social advantage or disadvantage when they determine
Because ill health can be an
an individual’s or group’s position in a social hierarchy (see the box on the next page).
obstacle to overcoming disad- Health disparities do not refer generically to all health differences, or even to all health differences
vantages, health disparities, warranting focused attention. They are a specific subset of health differences of particular relevance
which further disadvantage so- to social justice because they may arise from intentional or unintentional discrimination or
cially disadvantaged groups, marginalization and, in any case, are likely to reinforce social disadvantage and vulnerability.
seem particularly unfair. Disparities in health and its determinants are the metric for assessing health equity, the principle
Nondiscrimination and equality. underlying a commitment to reducing disparities in health and its determinants; health equity is
Every person should be able to social justice in health.
achieve his/her optimal health
status, without distinction based
on race or ethnic group, skin obligation to maximize the well- governments to respect, protect, housing, environmental protec-
color, religion, language, or na- being of those worst off. An fulfill, and promote all human tion, and other factors that are
tionality; socioeconomic re- aversion to discrimination is rights of all persons, including also crucial to health and well-
sources or position; gender, also firmly rooted in United the ‘‘right to the highest attain- being.38
sexual orientation, or gender States policies, as exemplified by able standard of health’’ and the Health differences adversely af-
identity; age; physical, mental, the Civil Rights Act of 1964 right to a standard of living fecting socially disadvantaged
or emotional disability or ill- prohibiting discrimination on adequate for health and well- groups are particularly unac-
ness; geography; political or the basis of race, color, or na- being. Governments must dem- ceptable because ill health can be
other affiliation; or other char- tional origin; the 1954 Brown onstrate good faith in progres- an obstacle to overcoming social
acteristics that have been linked vs. Board of Education decision sively removing obstacles to re- disadvantage. This consideration
historically to discrimination or desegregating schools; the Hill alizing these rights.29 The United resonates with common sense
marginalization (exclusion from Burton Act of 1946 prohibiting States signed but did not ratify notions of fairness, as well as
social, economic, or political hospitals receiving federal funds the International Covenant on with ethical concepts of justice,
opportunities). The groups rep- from discriminating on the basis Economic, Social, and Cultural notably, the concept that need
resented by these characteristics of race, color, or creed; and the Rights, which articulated the should be a key determinant of
substantively agree with those Americans with Disabilities Acts right to health. Signing a treaty, resource allocation for health,
specified by the United Nations of 1990 and 2008 prohibiting however, is considered an en- and Rawls’ notion of the obli-
Committee on Economic, Social discrimination on the basis of dorsement of its principles and gation to maximize the well-
and Cultural Rights as vulnera- physical or mental disability. reflects acceptance of a good being of those worst off.39
ble groups whose rights are at Health is also of special impor- faith commitment to honor its Sen noted as a ‘‘particularly se-
particular risk of being unreal- tance for society because a na- contents. The ‘‘right to health’’ rious . . . injustice . . . the lack
ized, due to historic discrimination’s prosperity depends on the (i.e., ‘‘the right of everyone to the of opportunity that some may
tion.32 This directly reflects the entire population’s health. enjoyment of the highest attain- have to achieve good health
human rights principles of Healthy workers are more pro- able standard of physical and because of inadequate social
nondiscrimination and equality; ductive and generate lower an- mental health’’37) is ‘‘not to be arrangements. . . .’’40 Sen argued
nondiscrimination includes nual medical care costs.34---36 understood as a right to be heal- that health is a prerequisite for
not only intentional but also A healthier population has thy,’’ because too many factors the capability to function nor-
unintentional or de facto more workers available for the beyond states’ control influence mally in society.31 It is therefore
discrimination, meaning dis- workforce. Health can facilitate health. Rather, it is ‘‘the right to particularly unjust that those
criminatory treatment embed- political participation, which a system of health protection who are socially disadvantaged
ded in structures and institu- is essential for democracy. which provides equality of op- should also experience addi-
tions, regardless of whether Rights to health and to a standard portunity to enjoy the highest tional obstacles to opportunity
there is conscious intent to dis- of living adequate for health. In- attainable level of health.’’ It in- based on having worse health.
criminate.32,33 The late philos- ternational human rights agree- cludes the right to equal access to Ratifying human rights agree-
opher John Rawls19 advanced ments, to which virtually all cost-effective medical care as ments obliges governments to
the concept of a society’s ethical countries are signatories, obligate well as to child care, education, direct special effort toward

e2 | Analytic Essay Forum | Peer Reviewed | Braveman et al. American Journal of Public Health | Published online ahead of print May 5, 2011


equalizing the rights of vulner- those who were worse off to demonstrated. Differences among difficult to overcome social disad-
able groups facing more obsta- start, within an overall strategy groups in their levels of social vantage. This reinforcement or
cles to realizing their rights. A to improve everyone’s health. advantage or disadvantage, which compounding of social disadvan-
nonexhaustive list of vulnerable Closing health gaps by worsen- can be thought of as where tage is what makes health dispar-
groups is specified in human ing advantaged groups’ health is groups rank in social hierarchies, ities relevant to social justice even
rights documents on non- not a way to achieve equity. are indicated by measures when knowledge of their causa-
discrimination and equal- Reductions in health disparities reflecting the extent of wealth, tion is lacking. It is important to
ity.32,37,41,42 (by improving the health of the political or economic influence, define health disparities without
The resources needed to be socially disadvantaged) are the prestige, respect, or social accep- requiring proof of causality, be-
healthy (i.e., the determinants of metric by which progress to- tance of different population cause there are important health
health, including living and ward health equity is measured. groups. disparities for which the causes
working conditions necessary for have not been established, but
health, as well as medical care) HEALTH DISPARITIES: Systematic But Not which deserve high priority based
should be distributed fairly. To DEFINITION AND Necessarily Causal Links With on social justice concerns. For
do so requires considering need RATIONALE Social Disadvantage example, the large Black---White
(along with capacity to benefit16 As noted by Starfield,45 health disparity in low birth weight
and efficiency17) rather than We briefly define health dis- disparities are systematic, that is, and premature birth strongly pre-
ability to pay or influence in parities and health equity (see the not isolated or exceptional find- dicts disparities in infant mortality
society.17 This principle, along box on the previous page), elabo- ings. Health disparities are sys- and child development, and
with principles cited previously, rating further and explaining in tematically linked with social dis- likely in adult chronic disease.46
reflects the ethical notion of this section. We also discuss social advantage, and may reflect social Although the causes of racial
distributive justice (a just distri- disadvantage, a key concept for disadvantage, although a causal disparity in birth outcomes are
bution of resources needed for understanding disparities and eq- link does not need to be demon- not established,46 credible
health) and the human rights uity (see the box on this page). strated. Whether or not a causal scientific sources have identified
principles of nondiscrimination Health disparities are systematic, link exists, health disparities ad- biological mechanisms that plau-
and equality, as well as the plausibly avoidable health differ- versely affect groups who are al- sibly contribute to the dispar-
right to a standard of living ade- ences adversely affecting socially ready disadvantaged socially, put- ities,46---50 which reflect phenom-
quate for health. Investments disadvantaged groups. They may ting them at further disadvantage ena shaped by social contexts and
in medical care intended to reflect social disadvantage, al- with respect to their health, thus are, at least theoretically,
reduce disparities must be though a causal link need not be thereby making it potentially more avoidable.
weighed against other poten-
tially more effective invest-
ments that address disparities
in other health determinants.38
Social Disadvantage
Health equity is the value under-
Health disparities and health equity cannot be defined without defining social disadvantage.
lying a commitment to reduce and
Social disadvantage refers to the unfavorable social, economic, or political conditions that some
ultimately eliminate health dis-
groups of people systematically experience based on their relative position in social hierarchies.
parities. It is explicitly men-
It means restricted ability to participate fully in society and enjoy the benefits of progress. Social
tioned in the Healthy People disadvantage is reflected, for example, by low levels of wealth, income, education, or occupational
2020 2 objectives. Health eq- rank, or by less representation at high levels of political office. Criteria for social disadvantage can
uity means social justice with be absolute (e.g., the federal poverty threshold in the United States is based on an estimate of the
respect to health and reflects the income needed to obtain a defined set of basic necessities for a family of a given size)43 or relative
ethical and human rights con- (e.g., poverty levels in a number of European countries are defined in relation to the median
cerns articulated previously. income, e.g., less than 50% of the median income).44
Health equity means striving to Not all members of a disadvantaged group will necessarily be (uniformly) disadvantaged, and not all
equalize opportunities to be socially disadvantaged groups will necessarily manifest measurable adverse health consequences.
The extent (whether in a single or multiple domains), depth (severity), and duration (e.g., across
healthy. In accord with the
multiple generations) of disadvantage matter. Social disadvantage is different from unavoidable
other ethical principles of be-
physical disadvantage due to, for example, an unavoidable physical disability. However, when
neficence (doing good) and
disabled persons are put at an unnecessary disadvantage in society due to lack of feasible
nonmalfeasance (doing no supports (e.g., accessible public buildings and transportation) or to discrimination against them in
harm), equity requires con- hiring for work that they could perform, this would constitute social disadvantage,
certed effort to achieve more reflecting discriminatory treatment, whether intentional or unintentional.
rapid improvements among



Plausibly Avoidable and efficiently to reduce important Disadvantaged Groups Are Not issue is whether the group has been
Differences in Health Given disparities. Necessarily Uniformly on the whole more disadvantaged
Sufficient Political Will Disadvantaged than Whites. Ample evidence has
It must be plausible, but not Worse Health Among Socially Internationally recognized hu- documented a longstanding pattern
necessarily proven, that policies Disadvantaged Groups man rights documents provide of less wealth,60,61 lower incomes,
could reduce the disparities, in- Socially disadvantaged groups guidance on which groups are lower educational attainment, and
cluding not only policies affecting are defined a priori, according to disadvantaged. Although health under-representation in positions
medical care but also social poli- criteria consistent with human disparities are systematic, a so- of high occupational rank56 and
cies addressing important non- rights principles regarding non- cially disadvantaged group will financial and political power62
medical determinants of health discrimination and equality. not necessarily fare worse on all among Blacks as a group com-
and health disparities, such as a Health disparities and equity health indicators, and might fare pared with Whites. Despite an end
should be central considerations better on some. For example, non- to legal racial segregation decades
decent standard of living; a level of
for public policy relevant to Hispanic European American or ago, racial residential segregation
schooling permitting full social
health, but they are not the only White (hereafter ‘‘White’’) women persists and with it, de facto edu-
participation, including participa-
considerations. Other legitimate over age 40 have higher incidence cational segregation, condemning
tion in the workforce and political
considerations include the mag- of breast cancer than non-His- many Black children to poor
activities; health-promoting living
nitude of impact and proportion quality schools. This reduces their
and working conditions, includ- panic African American or Black
of the population affected, as chances of obtaining good jobs
ing both social and physical envi- (hereafter ‘‘Black’’) women,54 and
well as efficiency in the use of with adequate income as adults,
ronments; and respect and social babies born to Hispanic immigrant
resources. If a more socially perpetuating social disadvantage
acceptance.23,51 This criterion women often have more favorable
advantaged group happens to across generations.63,64
addresses the issue of avoidability, birth weights than those born to
fare worse on a particular health Similarly, although many
which is central to Whitehead’s non-Hispanic Whites.55 Neither of
indicator, this may be a very im- United States women are affluent
these differences– –although both
definition of health inequalities; it portant issue that public health and some now hold high profes-
deserve public health attention– –
strives for more specificity about or other sectors should energeti- sional and political offices, as
would be a health disparity by the
avoidability and to clarify the bur- cally address; but it is not part of a group, they are more likely
proposed definition. Regardless
den of proof regarding causality.21 a ‘‘health disparities’’ agenda, than men to be poor,65 to earn
of this type of exception in relation
Avoidability can be highly sub- which focuses on improving the less at a given educational level,66
to a health outcome, Whites as
jective. For example, one person health of socially disadvantaged and to be underrepresented in
may believe that ill health caused groups. a group are more socially advan- high political office.67 Human
by poverty is avoidable; another, taged than Blacks and Hispanics, rights documents on nondiscrim-
however, may believe that both The Need to Reduce as data on income, wealth, educa- ination explicitly name women as
poverty and ill health among the Disparities in the tion, occupations, and political a vulnerable group warranting
poor are inevitable; hence, these Determinants of Health office have documented.56---58 special protection from discrimi-
disparities are unavoidable. Ac- Health determinants include Furthermore, on most health indi- nation. Patterns suggesting clini-
cording to the proposed definition, not only medical care but also the cators, including breast cancer mor- cally unjustified underreceipt of
the criterion is whether the given quality of the social and physical tality, White women are healthier certain cardiac treatments by
condition is theoretically avoidable, conditions in which people live, than Black women.59 Similarly, women compared with men68
based on current knowledge of work, learn, and play.23,51,52 higher rates of a preventable would reflect a gender disparity
plausible causal pathways and bi- Evidence of disparities in health illness in 1 of 2 affluent geographic in a determinant of health
ological mechanisms, and assuming determinants is thus relevant to regions would warrant public (medical care, in this instance).
the existence of sufficient political assessing disparities in health. health action, but not as a health Shorter life expectancy among
will. The more solid the knowl- Society will generally be more disparities concern. men in general, if likely avoid-
edge, the more reasonable and motivated to address health dif- The fact that not all members able, would clearly be an issue of
politically viable it will be to invest ferences that appear to result of a disadvantaged group (e.g., public health importance based
resources in interventions; feasi- from modifiable circumstances Blacks) appear to be severely dis- on the magnitude of potential
bility, costs, and potentially harm- over which individuals may have advantaged (e.g., we have a Black population impact. However,
ful unintended consequences little control21,53; for example, United States President, and men as a group have more
must be considered. Without firm the quality of local schools, ex- some Blacks are highly educated, wealth, influence, and prestige, so
knowledge to guide specific inter- posure to pollution or crime, in high professional positions, this difference would not be
ventions, pursuing health equity or absence of stores selling nu- and/or wealthy) does not contra- a social injustice and, therefore,
would require supporting research tritious food in one’s neighbor- dict considering that group as not a health disparity or equity
on how to intervene effectively hood. generally disadvantaged. The issue.



Health Disparities as the Health inequity, however, is a Limitations advantage. The causes need not be
Metric to Assess Progress forceful term tending to imply These definitions do not pro- known definitively, if it is biologi-
Toward Health Equity a strong judgment about causality, vide numerical cutoffs for deter- cally plausible that the difference
The stated criteria permit the which may be difficult to support in mining disadvantage. Nor do they could be reduced by policies.
assessment of measurable prog- many cases that nevertheless de- remove completely the need to These definitions also ground the
ress toward greater health equity. serve attention as health disparities exercise judgment based on values concepts of health disparities and
Systematic associations with social (i.e., health differences adversely that are likely to vary across in- health equity in internationally
disadvantage can be identified by affecting socially disadvantaged dividuals and societies. It is recognized principles from the
observing a repeated pattern of groups) regardless of their causa- difficult to imagine reasonable fields of ethics and human rights,
correlations between measures of tion. As with health equity, mea- definitions of these concepts, giving them universality and du-
social disadvantage and a health suring health inequity relies on however, that would provide rigid rability. Although human rights
outcome. Social advantage and health disparities as the metric. cutoffs, would completely pre- are often honored more in the
disadvantage can be measured by clude the exercise of judgment, breach than in the observance,
comparing populations on factors Health Disparity: Not Just and would leave no room for they are a powerful resource in
such as levels of wealth, income, a Health Difference contention. The proposed defini- that they represent a global con-
educational attainment, or occu- Interpreting the term ‘‘health tions do not clarify whether the sensus on values. This consensus
pational rank, for example (see the disparities’’ as any health differ- reference group for making eq- can be an important point of ref-
box on page e3). Demonstrating ences among any population erence in national and local de-
uity/disparities comparisons
that a given disparity is plausibly group, as has been done by some bates on policies and practice in
should be the most advantaged
federal agencies, encompasses the the United States. It would be
avoidable and can be reduced by group in one’s country or in the
entire domain of epidemiology, naıve to think that achieving con-
¨
policies requires being able to de- world; using one’s country as the
which is the study of the distribu- sensus on a definition would ob-
scribe, at least in general terms, 1 reference point may ignore the
tion of diseases and risk factors viate the need for constant vigi-
or more potential causal pathways better health achieved by advan-
across different populations. We lance to ensure that the agenda for
that are consistent with current taged populations in other parts of
have argued that the term health research and action on health dis-
scientific knowledge; it does not the world.
disparities should be used advis- parities remains on track and true
require definitively establishing
edly, in the spirit of the movement to the essence of the definition;
either the causation of the dispar- Challenges Addressed
for social justice from which the however, having a clear definition
ity or proving the effectiveness of The definitions address major
term emerged, to refer to a partic- is crucial.
existing interventions to reduce challenges, such as identifying the
ular subset of differences in health
it. Guidelines for measuring health social groups to be compared and
that meet well-specified criteria The Issue is Justice
disparities are available.9,69---73 specifying the general criteria for
of specific relevance to social jus- Could this approach– –putting
Increasingly, the term ‘‘health appropriate reference groups for
tice. The definitions proposed here health disparities within the
inequity’’21,74,75––the opposite of these comparisons.18 These chal-
were designed to clarify the con- broader context of ethics and hu-
health equity– being used in-
–is lenges have arisen when consid-
cepts of health disparities and man rights– –jeopardize the limited
stead of ‘‘health disparity’’ to cap- ering health disparity or equity resources allocated to specifically
health equity in ways that could
ture explicitly the moral dimension stand up to rigorous conceptual issues, with serious implications address racial/ethnic disparities,
and differentiate health differences scrutiny as a basis for guiding for resource allocation. These by spreading these resources more
thought to reflect injustice from policy and practice and ensuring definitions remove the need to thinly among other disadvantaged
health differences in general. Ex- accountability, which requires establish the causality and avoid- groups? Would broadening the
amples of health differences that clear criteria for measure- ability of each health difference for definition make the concept too
would not be considered health ment.9,69,70 To achieve the de- it to qualify as a health disparity abstract and therefore less com-
disparities according to our defi- sired rigor, the full versions of the worthy of special attention. To ad- pelling to the public and policy-
nitions (see the box on page e2) proposed definitions are complex dress the difficult issue of causality, makers? We concluded that the
include: elderly adults generally and technical and will not be suit- our definitions acknowledge that struggle for racial justice, in which
having worse health than noneld- able for all audiences; for many a health disparity may or may not efforts to eliminate racial/ethnic
erly adults; skiers being at higher audiences, it may be most appro- arise from social disadvantage, but disparities in health are crucial,
risk of long-bone fractures than priate to define health disparities it must adversely affect members of has far more to gain than to lose
nonskiers; and men not having simply as worse health among socially disadvantaged groups; this from making these principles ex-
obstetric problems, whereas socially disadvantaged groups can be assessed using epidemiologic plicit. The relevant ethical and
women do. Both ‘‘health disparity’’ and then elaborate as necessary, data revealing repeated and perva- human rights principles support
and ‘‘health inequity’’ have their drawing on the more comprehen- sive associations between health prioritizing attention to those fac-
place in the public health lexicon. sive form of the definitions. indicators and measures of social ing the greatest obstacles, and



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We wish to thank Karen Simpkins, MLS,
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