Your opportunity to influence what could be an important new tool to address health equity is fast approaching. Beginning on April 9, we will be launching a global consultation on a draft guide to a promising approach to addressing vast health inequities within countries, National Health Equity Strategies. We invite you to join us.
The O’Neill Institute, in partnership with Stop TB, USAIDS, and many others who have been generous in giving their time and ideas, has developed this guide as a tool to enable countries to achieve universal health coverage that is truly universal and, beyond that, to live up to the central promise of the Sustainable Development Goals: to Leave No One Behind.
Today’s health inequities mean that in countries rich and poor, people living in different neighborhoods in the same city may have life expectancies that differ by a decade, or even several decades. Such differences even among neighbors arise from a host of factors. These include different levels of access to quality health care, but extend much deeper into people’s overall life conditions, from the air they breathe (who lives in the most polluted areas?) to the water they drink (who does not have access to safe drinking water?), from the safety of their streets (who lives in neighborhoods with the greatest crime?) to the quality of their jobs (who works in the most dangerous industries)?
As we recently described in more detail, this approach to health equity is one that would both cover a full range of the determinants of health – health equity cannot be achieved otherwise – and all populations who are experiencing these inequities. The health equity strategies and specific actions to achieve them would be incorporated into national plans in the health and other sectors. Critically, the strategies would be developed in a highly participatory manner, with leadership drawn from marginalized populations, from populations suffering from these health inequities, with poorer health — and all the life consequences of poorer health.
I noted above that our partners for this initiative include Stop TB, yet the strategies would encompass all health issues, by no means limited to tuberculosis (TB). What, then, is the link to TB? The answer goes to the nature of TB – and to why, if we are truly concerned about particular health issues, a sweeping approach to health equity such as National Health Equity Strategies is a very valuable way to go.
TB is a disease of social, economic, and political marginalization. Marginalized populations suffer from TB disproportionately – in some cases dramatically so. Many indigenous peoples experience TB rates that are dozens of times higher than their non-native national counterparts; and 270 times higher in the case of Inuit people of Canada. Prisoners similarly experience vastly disproportionate high levels of TB; one study involving Mexican prisons found TB prevalence 1,000 times that of the general population. Other populations with disproportionately high levels of TB, such as migrants, urban slum dwellers, and homeless populations, are also severely marginalized and experience a range of health inequities.
There are no biological realities of these groups that increase their vulnerability to TB. Rather, their vulnerability comes from their social realities, such as overcrowded and unsanitary living conditions, poor nutrition, and lack of access to quality health care. It will take more than targeted outreach or other focused interventions to end their heightened vulnerability to TB. To address TB, these underlying conditions – and the human rights violations that contribute to them – urgently need to change.
This is not new, of course. A decade ago, the Commission on the Social Determinants of Health highlighted the centrality to our health of the totality of our lives and the social and environmental factors that affects us. And it was hardly the first to point to the importance of the social determinants of health, long understood in the field of public health.
Yet our response is deeply inadequate, though approaches such as Health in All Policies and health impact assessments are grounded in this understanding. The fifteen years of the Millennium Development Goals, for all their progress in improving global health – and from reduced maternal and child mortality to increased AIDS treatment, there were immense gains – they did little for health equity within countries. There, progress was generally limited, and entirely absent in some cases. In 2000, women in the top wealth quintile in developing countries were three times more likely (p. 2) than women in the poorest wealth quintile to deliver with the assistance of a skilled birth attendant. The same was true in 2014. And during the same period, while in upper-middle-income countries the stunting gap between children in rich and poor households generally decreased, that gap increased in many lower-income countries (p. 10).
To bring an end to these health inequities, only a deliberate, comprehensive approach will do, beginning to address not only health inequities directly, but through action on key determinants of health, participatory approaches, and accountability, undercutting marginalization itself. That is precisely the intent of National Health Equity Strategies. Join our consultation, and together, let us take on health inequity.