Longwoods Blog

Equity – a blog
Ontario’s Ministry of Health and Long-Term Care (MOHLTC) has identified equity as a key component of quality care. The Ministry has developed a Health Equity Impact Assessment (HEIA) to support improved health equity, including the reduction of avoidable health disparities between population groups. HEIA also supports improved targeting of healthcare investments—the right care, at the right place, at the right time. And that is what this blog covers. Join us in the conversation.

Cross-National Comparisons Yield a Blueprint for Achieving Health Equity

Unlike many problematic aspects of health itself, health inequities can be eliminated.  Examining health inequities in different societies reveals that they are not inevitable.  Rather, health inequities are the result of social actions (or inactions).  Because they are socially produced, their remedies must also be socially produced.   From citizens and communities to businesses and governments, we all have a role to play.  The evidence helps to provide a blueprint for action.

On the one hand, health inequities are present in every society, at every point in time, and for virtually every health outcome for which they have been measured.  The reason that health inequities are so pervasive is that they arise from the strong link between aspects of our socioeconomic identity – our gender, race, ethnicity, immigrant status, income level, education level, occupation – and the resources that are necessary both to have the everyday lived experiences which promote health and to avoid experiences which compromise health.

These resources are too numerous to mention in full, but include the opportunity to purchase nutritious foods, to exercise in a safe environment, to access housing that is affordable and in good repair, to have secure working and living conditions, and the like.  In turn, strong scientific evidence has shown that these forms of access and opportunity influence our behaviors (e.g., smoking, diet, exercise), our physiological systems (e.g. immune response, allostatic load (i.e. physiological stress)), and even the formation, expression, and intergenerational replication of our genes (particularly through the process of epigenesis).  Put differently, these resources have ‘material’, ‘social’, and ‘psychological’ significance which together work to affect our biology – disadvantaging those with less access and opportunity and favoring those with more.

Indeed the pervasiveness of health inequities is a result of the innumerous mechanisms through which social identity affects human biology.  Health inequities cannot fully be resolved by tackling specific mechanisms; by trying to change health behaviors, developing new drugs, or promoting stress reduction techniques.  Richer and other more socioeconomically advantaged people tend to have healthier lifestyles not because they were taught ways in which to do so, but because they have the resources to do so.  We must address the fundamental cause of health inequities: the tie between our social identity and health resources themselves.

On the other hand, the extent and character of this tie varies tremendously between societies and thus so too do the extent and character of health inequities.  What is particularly remarkable is that a nation’s overall wealth is not the only – or even primary – reason some societies seem to have been more successful than others at reducing health inequities.  This is evident by examining Canada and its peer nations (typified by the member-nations of the Organization for Economic Cooperation and Development (OECD)).  Even among these countries, which all can claim a longstanding history of economic prosperity, stable development of political and social institutions, and a high degree of autonomy over how to structure their societies, health inequities are very large in some, but quite muted in others.

More specifically, research has demonstrated that cross-national differences in health inequities amongst these societies are principally driven by cross-national differences in the health status of those whom are more resource disadvantaged.  That is, across the world’s economically advanced nations, those at the higher rungs of the socioeconomic ladder have similar health status; it is those at the lower rungs whom have the most disparate outcomes.  The Scandinavian countries exemplify societies which exhibit the best health outcomes among their disadvantaged populations.  At the other end of the spectrum of wealthy countries lies the United States, which exhibits the widest health inequities.  Canada, though so far faring better than the United States, has much work to do.  It is significant to note that this cross-national patterning has also lead to the important insight that a society’s health inequities are very much connected to – and very much support – its average health as well; those nations with smaller health inequities tend to have higher average health status while those with larger inequities have lower average health status.

From these cross-national observations and other relevant areas of research, we can infer a series of guiding principles, though we still require much deeper understandings of the complex connections between society and human health.  First, differences across countries in the health of the disadvantaged suggest the effects of disadvantage can be, at the very least, mitigated.
Second, mitigating the role of disadvantage requires both changing the extent of socioeconomic inequity itself (such as the extent of income inequality) and the extent to which socioeconomic identity is tied to access, opportunity, and resources (such as the extent of race/ethnic or income based differences in neighborhood quality).

Third, the ways in which we can accomplish these goals have very personal elements (such as the way we treat those with whom we live, work, and go to school) but also very institutional elements (such as the ways we decide to fund neighborhood projects, set rules about job conditions, and plan tax and transfer policies).  Moreover, the personal and the institutional are very much related to each other.

Fourth, policies are a powerful means of creating widespread change in access to resources and opportunities and also can serve to support individuals and communities to create local changes.

Finally, and perhaps most importantly, we must be guided in all of our actions by the principle of equity.  If we lead by this goal, then elimination of health inequities is sure to follow.  More muted health inequities in Scandinavia reflect greater success in applying these principles than can be said of Canada or the United States.  Canada must work harder to connect with these principles.  This will require sustained collaborative engagement of many sectors of society – communities, NGO’s, government, business, the health care sector, and academe.

About the Author:

Arjumand Siddiqi is currently Assistant Professor at the University of Toronto Dalla Lana School of Public Health and an Associate Member of the Canadian Institute of Advanced Research Program on Successful Societies.  Dr. Siddiqi is interested in the role that societal conditions play in shaping inequities in population health and human development. In particular, her research utilizes a cross-national comparative perspective to understand the consequences of social welfare policies for inequalities in health and developmental outcomes.  Areas of research include the influence of income inequality and social policies on inequities in schooling outcomes amongst the advanced market economies, and an emerging body of work to understand health inequities in Canada versus the United States. Dr. Siddiqi was formerly Assistant Professor at the UNC Gillings School of Global Public Health, and a Faculty Fellow of the Carolina Population Center.  She was a member of the World Health Organization’s Commission on Social Determinants of Health Knowledge Hub on Early Child Development, and has consulted to several international agencies including the World Bank and UNICEF.  Dr. Siddiqi received her doctorate in Social Epidemiology from Harvard University.

This entry was posted on Friday, March 30th, 2012 at 9:01 am and is filed under Longwoods Online.