Diversity and Equality in Health and Care (2017) 14(3): 148-152 2017 Insight Medical Publishing Group Review Article TheResearch History Article of Health Equity: Concept and VisionOpen Access Elizabeth Fee* and Ana Rita Gonzalez Princeton University, Florida, 33176, USA ABSTRACT Health equity has long been an ideal, with roots in social the terms “health equity” and “inequity” in their statements medicine reaching back into the mid-nineteenth century when of mission and purpose. In 1971, Julian Tudor Hart coined visionary public health leaders and social critics recognized the Inverse Care Law: "The availability of good medical care that social and class inequalities led to inequities in health. tends to vary inversely with the need of the population served.” The Constitution of the World Health Organization states that Other analysts have pointed out that medical care is only one “the highest standards of health should be within reach of all, of the requirements for good health, with income, education, without distinction of race, religion, political belief, economic nutrition, sanitation, and living and working conditions all or social condition”. The Universal Declaration of Human being essential determinants of health. Margaret Whitehead Rights of the United Nations states that “everyone has the right has emphasized the difference between health differentials that to a standard of living adequate for the health and well-being are unavoidable, and those that are avoidable and preventable; of himself and of his family” and that “Everyone is entitled the latter were health inequities and recognized as injustices. to all the rights and freedoms set forth in this Declaration, This essay traces the history of the idea of health equity and without distinction of any kind, such as race, color, sex, raises questions about the translation of the concept into language, religion, political or other opinion, national or social practice. origin, property, birth or other status”. Various organizations- Keywords: Equity; Health equity; History; Human rights; the Rockefeller Foundation, the World Bank, and many non- Health disparities; Inequalities; World Health Organization governmental organizations (NGOs) have frequently used What is known about this topic? Although there is a considerable literature on health equity, we are not aware of any existing historical analysis. We believe that this paper is thus an entirely original contribution to the literature. Introduction economic or social condition [1].” Two years later, in 1948, the United Nations, in a response to the Nazi holocaust, adopted the There is an African proverb that says “Until the lions have Universal Declaration of Human Rights [2] which set a standard their historians, tales of the hunt shall always glorify the hunter.” by which the human rights activities of all nations, rich and poor The intention to eliminate unfair and avoidable differences alike, were to be measured. It states that “everyone has the right between disadvantaged groups that have poorer survival to a standard of living adequate for the health and well-being rates, life conditions, and health status - that perpetuate their of himself and of his family, including food, clothing, housing disadvantage – is at the core of health equity. It is not entirely and medical care and necessary social services, and the right clear when and who coined this concept, but many health to security in the event of unemployment, sickness, disability, care systems, health organizations, and thought leaders have widowhood, old age or other lack of livelihood in circumstances considered health equity as the North Star of health care. beyond his control.” It also states that “Everyone is entitled to Practice, however, has been far from the ideal; and the ideal has all the rights and freedoms set forth in this Declaration, without failed to translate into equitable and equally healthy societies. distinction of any kind, such as race, color, sex, language, Early Declarations and Discussions of Health Equity religion, political or other opinion, national or social origin, property, birth or other status” [3]. The origins of the concept of health equity can be found in the history of social medicine, especially since the mid-nineteenth Twenty-three years later, in 1971, Julian Tudor Hart coined century. Men such as Rudolf Virchow, Friedrich Engels, what he termed “the inverse care law” in his article about the Andrija Stampar, and others clearly recognized that social and British National Health System (NHS). As he described the class inequalities led to inequities in health. This essay traces inverse care law: “the availability of good medical care tends to the subsequent history of the concept of health equity, and poses vary inversely with the need of the population served.” [4]. This questions about the translation of this idea into practice. was, of course, a play on the inverse square law of physics. Hart said that the inverse care law could be observed at its fullest The World Health Organization (WHO) Constitution (1946) extent when medical care was exposed to market forces, and proclaimed that “the highest standards of health should be within argued that “a just and rational distribution of the resources of reach of all, without distinction of race, religion, political belief, medical care should show . at least a uniform distribution.” Community-based Research 149 Elizabeth Fee Referring to a publication by Richard Titmuss on the 15 first awareness and stimulating debate, and to educate those, within years of the British National Health System [5], Hart noted that or outside the health sector, whose policies could have an “the higher income groups know how to make better use of the influence on health. She outlined consistent evidence showing service; they tend to receive more specialist attention; occupy that disadvantaged groups had poorer survival chances, and more of the beds in better equipped and staffed hospitals; died at a younger age than more favored groups [10]. In receive more elective surgery, have better maternal care, and are every part of the European Region, in every type of political more likely to get psychiatric help and psychotherapy than low and social system, there were marked differences in health income groups -- particularly the unskilled [4].” Hart argued between different social classes, different geographical areas that the large social inequalities of mortality and morbidity, and in the same country, and notably large gaps in mortality rates the equally large differences in the quality and accessibility of between urban and rural populations, the young and the elderly, medical resources, could not be solved by simply improving and diverse ethnic groups. Furthermore, those who were most care for everyone, but that a redistribution of resources was in need of medical care, including preventive care, were the necessary. He also stated that “medical services are not the least likely to receive it. National health policies could hardly main determinant of mortality or morbidity; these depend most claim to be concerned about the health of all the people if the upon of standards of nutrition, housing, work environment, and heaviest burden of ill-health borne by the most vulnerable was education, and the presence or absence of war” [4]. not addressed. The concept of health equity was strongly endorsed by Whitehead [10] addressed seven main determinants of the participants in the World Health Organization’s (WHO) health where differentials could be identified: Conference on Primary Health Care in Alma-Ata in 1978. ••Natural, biological variation The launch of “Health for All” campaign (HFA), implicitly made health equity a priority for all countries [6]. The Alma- ••Health-damaging behavior if freely chosen, such as Ata Declaration viewed health as part of and an impetus for participation in certain sports and pastimes development, with every social sector needing to collaborate ••The transient health advantage of one group over another in the production and maintenance of “health for all.” Clean when that group is first to adopt a health-promoting water and sanitation systems were necessary to control diarrheal behavior (if other groups had the means to catch up) diseases; improved conditions of housing and shelter were needed to contain tuberculosis and respiratory disorders; good ••Health-damaging behavior where the degree of choice of nutrition was an important foundation of good health; and lifestyles was severely restricted poverty was the foundation of much illness. The Alma-Ata ••Exposure to unhealthy, stressful living and working Declaration highlighted the inequality between the developed conditions and the developing countries and termed it politically, socially, and economically unacceptable [7]. ••Inadequate access to essential health and other public services; and The WHO is organized by regions, each having some commonality of geography, culture, and epidemiological pattern ••Natural selection or health-related social mobility involving of disease [8]. After the Alma-Ata Conference, the WHO the tendency for sick people to move down the social scale Regional Office for Europe established a program on Equity in Whitehead [10] pointed out that some of these differences Health to examine issues of unemployment, poverty, and health, and differentials were unavoidable and, although they were with reference to several vulnerable groups. A strong network “inequalities,” they were therefore