Reviews Book

Public Health, Ethics, and Equity

BMJ 2005; 330 doi: (Published 28 April 2005) Cite this as: BMJ 2005;330:1031
  1. John Lynch (jwlynch{at}, associate professor of epidemiology
  1. University of Michigan, United States

    Health has improved enormously over the 20th century. The 2003 United Nations Human Development Report shows that one indicator of health, average life expectancy at birth, now exceeds 70 years in almost half the world's countries and in 45% of the world's population (my calculations). But although health has improved it has not been shared equally within or among countries, and this is an affront to a sense of social justice. When the capacity exists for generating social goods that enhance health for some individuals, communities, or countries, then it is a priority to extend that capacity for generating better levels of health to everyone else.

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    Eds Sudhir Anand, Fabienne Peter, Amartya Sen

    Oxford University Press, £55, pp 400 ISBN 0199276366

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    Public Health, Ethics, and Equity concerns the fairness of the unequal distribution of health within and among countries. In various ways it provides informative perspectives that help readers explore some of these issues:

    • What is meant by “fairness”? Are there principles of social justice that apply to health?

    • What is meant by “unequal distribution”? How should the size of health inequalities be measured?

    • Is the goal to have equity in health (as an outcome) or equity in the inputs or opportunities to generate good health?

    • What is the balance of individual and social responsibility for health?

    • How broadly should “health” be defined, and how sensitive should it be to local expectations of health?

    • What social groups are of most concern in assessing health equity?

    It will be no surprise to regular readers of this journal that investigating health inequality is an important topic in the medical and public health literature. Concerns over health equity are evident on national and international health agendas. On 18 March 2005 the World Health Organization continued its commitment to the longstanding “health for all” initiative by launching a Commission on the Social Determinants of Health, where equity is a major focus ( In the United States, the second overarching aim of the major goalsetting document for public health, Healthy People 2010, calls for the elimination of health disparities among different social groups, despite the lack of a consensus on how to define “health disparity,” let alone measure progress towards its elimination. Similarly, spirited debate over the conceptual basis, empirical assessment, and policy options to improve health equity can also been seen in public forums, internet discussion groups, and in the scientific literature (BMJ 2001;323: 678-81).

    Public Health, Ethics, and Equity is thus timely. The editors have compiled a set of papers originally presented at seminars held at Harvard University in 1998 and 1999. The premise for these seminars was that although a great deal of empirical research had documented the extent of health inequalities, there had been less development and appreciation of the normative underpinnings of concepts of health equity. Although many of the papers—by some of the most distinguished authors in the field and embracing perspectives from several disciplines, including economics, medicine, epidemiology, sociology, philosophy, and anthropology—have been published else-where it is useful to have them bound in one volume, because they are some of the most significant contributions to the discourse on health equity.

    Everyone agrees that health inequities exist and that we need to reduce them. As health equity research and policy move from documentation to action, we have reached a stage where we need to explore and understand the conceptual and ethical basis that should inform goal setting, measurement, and evaluation of progress towards improving health equity. Ultimately, that will involve forms of public and political discourse that will no doubt, in part, draw on the powerful ideas presented in this book.

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