The distinction between health inequality and health inequity

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GLOSSARY

A glossary for health inequalities
I Kawachi, S V Subramanian, N Almeida-Filho
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J Epidemiol Community Health 2002;56:647–652

In this glossary, the authors address eight key questions pertinent to health inequalities: (1) What is the distinctionbetween health inequality and health inequity?; (2) Should we assess health inequalities themselves, or social group inequalities in health?; (3) Do health inequalities mainly reflect the effects of poverty, or are they generated by the socioeconomic gradient?; (4) Are health inequalities mediated by material deprivation or by psychosocial mechanisms?; (5) Is there an effect of relative income onhealth, separate from the effects of absolute income?; (6) Do health inequalities between places simply reflect health inequalities between social groups or, more significantly, do they suggest a contextual effect of place?; (7) What is the contribution of the lifecourse to health inequalities?; (8) What kinds of inequality should we study?..........................................................................

3 Do health inequalities mainly reflect the effects of poverty or are they generated by the socioeconomic gradient? 4 Are health inequalities mediated by material deprivation or by psychosocial mechanisms? 5 Is there an effect of relative income on health, separate from the effects of absolute income? 6 Do health inequalities between places simply reflect health inequalitiesbetween social groups or, more significantly, do they suggest a contextual effect of place in shaping inequalities in health? 7 What is the contribution of the life course to health inequalities? 8 What other kinds of inequality should we study?

THE DISTINCTION BETWEEN HEALTH INEQUALITY AND HEALTH INEQUITY
Inequality and equality are dimensional concepts, simply referring to measurable quantities.Inequity and equity, on the other hand, are political concepts, expressing a moral commitment to social justice. Health inequality is the generic term used to designate differences, variations, and disparities in the health achievements of individuals and groups. A straightforward example of health inequality is higher incidence of disease X in group A as compared with group B of population P. Ifdisease X is randomly or equally distributed among all groups of population P, then there is no presence of health inequality in that population. In other words, health inequality is a descriptive term that need not imply moral judgment. To further illustrate this point, imagine individual A who dies at age 40 during a sky diving accident. His identical twin, B, who does not enjoy this hobby,lives to age 80. In this case, the unequal life spans of A and B (and for that matter, the unequal life expectancies of recreational sky divers and non-divers) reflects a personal choice that would not necessarily evoke moral concern. Besides such voluntarily assumed risks, other examples of health inequality that we would not normally consider unjust include pure chance (for example, a random geneticmutation—unlucky but not unjust) and life stage differences (for example, a 20 year old having better health than a 60 year old, but expected to succumb to the same slings and arrows of infirmity 40 years on). That said, many forms of health inequalities are also undoubtedly inequitable. Health inequity refers to those inequalities in health that are deemed to be unfair or stemming from some formof injustice. Whitehead and Dahlgren 11 proposed additional considerations

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Correspondence to: Professor I Kawachi, Department of Health and Social Behavior, Harvard School of Public Health, 677 Huntington Avenue, Boston MA 02115, USA; Ichiro.Kawachi@ channing.harvard.edu

he burgeoning field of health inequalities...