Public health, ethics, and equity

Public health, ethics, and equity Editors: Sudhir Anand, Fabienne Peter, and Amartya Sen Publisher: Oxford University Press, Oxford; 2004 ISBN: 0-19-927636-6; hardback; 328 pages; price: 55 [pounds sterling] We live in a world with staggering inequalities in health. In Australia, Japan, Sweden, and Switzerland, the average life expectancy is greater than 80 years, But in Angola, Malawi, Sierra Leone, and Zimbabwe, the average life expectancy is less than 40 years. In Sweden, the under-5 mortality rate is 3 per 1000, while in Sierra Leone it is almost 300 per 1000. In Austria, Denmark, Spain, and Sweden, the maternal mortality rate is less than 6 per 100 000. But in Afghanistan, Chad, Rwanda, and Sierra Leone, the rate is greater than 1000 per 100 000. The situation is actually worse than these figures suggest because national averages tend to mask inequalities within a country, Within particular countries, health prospects vary significantly and systematically with race, ethnic group, gender, region, and socioeconomic class. Although the average life expectancy in America is 77 years, that of African-American men is closer to 70 years, The under-5-mortality rate in the north-east of Brazil is double the average in the rest of the country. And in most societies, there is a social gradient in health: groups higher along the socioeconomic curve enjoy better health. This is not a matter of absolute deprivation, but of relative standing, In many societies, relatively small differences in income and power make a significant difference to health. Although most public health interventions improve average health, many of them increase health inequalities within a society because they tend to benefit the better-off groups more than the disadvantaged. The universal immunization programme in India has achieved much higher coverage rates among families that are wealthier, more educated, and live closer to health centres. Smoking cessation programmes in the USA have had more effect among wealthier and better-educated groups. And years from now, I wouldn't be surprised to learn that public health programmes designed to combat obesity have effects that vary along socioeconomic lines. What, if anything, should we do about health inequalities within and between countries? What do justice and equity demand? These important ethical questions have received surprisingly little attention within bioethics. Most scholars have focused their attention on ethical issues that arise in treating individual patients, using human subjects for re, earth, and applying new technologies. Very few have focused their attention upstream, on the social determinants of health and the ethical issues that arise in population health. People in public health have not ignored the ethical issues raised by health inequalities, but they have tended to adopt approaches that are too simple to deal with the complexity of the problems. Some people have adopted an approach that emphasizes cost-effectiveness analysis, Although it makes sense to consider the amount of health that a given amount of resources can produce, this approach looks at overall averages and tends to ignore inequalities, Some scholars and activists in public health have adopted an approach based on the discourse of human rights. Although there are humanitarian reasons for claiming that health is a basic human right, the discourse of rights tends to ignore all the hard questions about priorities, duties, and responsibilities. More recently, some people in public health have begun to adopt an "equity perspective. …