Books & Electronic Media

Challenging inequities in health: from ethics to action

Edited by Timothy Evans, Margaret Whitehead, Finn Diderichsen, Abbas Bhuiya, & Meg Wirth Oxford University Press, New York, USA, 2002. Hb ISBN 0-19-513739-6 price £47.50 Pb ISBN 0-19-513740-X price £29.50

By presenting this collection of timely and interesting papers in a single volume, Evans et al. make a valuable contribution to the growing literature on social inequalities in health. The volume includes work from and about countries on all the continents, and a wide range of conceptual, methodological, and empirical approaches. Anyone concerned with achieving greater equity in health and development will appreciate its strong orientation to policy. Students and researchers will find the book a treasure chest of overviews and syntheses.

The work starts with conceptual issues, and a framework for analysis and the consideration of policy options. The model calls attention to diverse pathways leading to social differentiation in health, suggesting multiple entry points for policies that can change them, for example, by diminishing harmful exposures or vulnerability to them. Elements of this model are used effectively in many of the chapters, contributing to the coherence of the collection as a whole.

In the second part, on measurement, Anand et al. provide a useful review of the issues that arise in measuring social disparities in health. They emphasize that conclusions about the magnitude and nature of health disparities can vary according to the health indicator and social groups examined and the analytical technique chosen. Their discussion contrasting absolute and relative measures of inequality is particularly strong. Amartya Sen then presents several daunting challenges for assessing health equity. For example, while health should be assessed on the basis of "internal" (i.e. subjective) as well as "external" perceptions, lower expectations among worse-off people can make self-reported health assessments unacceptably biased. Furthermore, it may be a fundamental property of indicators reflecting quality of life that they cannot be meaningfully quantified.

In subsequent chapters of this section, various techniques are used to measure social inequalities in health in different countries. Liu et al. use secondary data sources to examine gender, geographic and socioeconomic disparities in health in the context of massive economic changes in China over the previous two decades. One of their conclusions is that the one-child family policy has probably exacerbated gender disparities in health. Dramatic declines in mortality in Japan since the 1920s appear to be more related to wealth in the case of men and education in the case of women. Premature mortality and disability in the USA vary according to income in all social groups, but the variation is greatly increased by racial/ ethnic and gender differences. Socioeconomic and health disparities in Chile, though marked and widening, have probably been significantly reduced, particularly for women, by public investment in education. In Russia, Shkolnikov et al. find, contrary to expectations, that mortality differentials associated with education and occupation around 1989 were no smaller than those in Western countries. Analysing the sharp rise in mortality during the 1990s, the authors conclude that sex role differences may affect the way in which men and women cope with stress caused by unemployment and the transition from a command to a market economy. The section ends with an analysis of the painful situation of poor adolescents in the United Republic of Tanzania, and an exploration of the policy implications.

Under the broad rubric of "tackling root causes", the third section ranges from a conceptual essay on gender, equity and health to country-specific analyses of selected health equity issues. These include road traffic accidents in Kenya which disproportionately victimize the poor; the effects of interventions on rural development, family planning, and gender equity in Bangladesh; and a fascinating analysis by Gilson & McIntyre of legal and policy mechanisms by which apartheid produced and maintained social stratification in health in South Africa. This is followed by a critical assessment of post-apartheid policy attempts to achieve greater equity. A study of Sweden and the United Kingdom then concludes that social policies can significantly alter the extent of the health disparities which accompany poverty and unemployment.

Questions of health financing are examined in the last group of studies. Here Hsiao & Liu present a useful conceptual framework and a clear, concise review of methods for quantifying equity in relation to various aspects of health care financing, using examples of measurement challenges in diverse countries. Lozano et al. use county-level data to demonstrate inequitable patterns of resource allocation for health in Mexico, and present a replicable methodology for monitoring them. Pham Manh Hung et al. conclude the section with a description of Viet Nam's efforts to achieve equity-oriented health care financing, which have considerable generalizability.

The conclusion, or at least the premise on which the conclusion is based, is that health inequities can indeed be reduced in the current global context. Recommendations include building consensus on values; setting targets for health equity; and monitoring progress towards those targets. Monitoring should also include the impact on equity of all policies that affect health, not just those of the health sector. The authors discuss the policy responses needed both internationally and nationally and call for a global mobilization of efforts to improve and safeguard equity by means of both advocacy and monitoring.

The book is, of course, not perfect. An abstract for each chapter would have been helpful, particularly given the range of material covered in some chapters. The conclusions from some of the country studies go far beyond the evidence they present. Inevitably in a volume with many contributors, there is some unevenness in quality, but the overall quality is excellent, and every chapter has something of value to convey. The editors have succeeded admirably in making a largely coherent whole out of disparate material from numerous authors all over the globe. This is achieved in part through the use of similar formats for presentation and extensive cross-referencing between chapters. Striking photographs provide an additional eloquent touch. Newcomers and seasoned researchers alike will find this collection of studies invaluable.

Paula Braveman1



1 Professor of Family and Community Medicine, University of California, San Francisco, 500 Parnassus Avenue, Room MU-306E, San Francisco, CA 94143-0900, USA (email:

World Health Organization Genebra - Genebra - Switzerland