Health inequalities: a global perspective

Centro de Pesquisas
Gonçalo Moniz, Fundação
Oswaldo Cruz. R. Waldemar
Falcão 121, Candeal. 40296-
710 Salvador BA Brasil.
[email protected]
Health inequalities: a global perspective
Abstract The objective of this article is to present health inequalities as a global problem which
afflicts the populations of the poorest countries,
but also those of the richest countries, and whose
persistence represents one of the most serious and
challenging health problems worldwide. Two
components of global inequalities are highlighted: inequalities between groups within the same
society, and inequalities between nations. The
understanding that many of these inequalities are
unjust, and therefore inequities, is largely derived
from the inequalities that are identified between
the various social groups of a given society. Inequalities between different societies and nations,
while relevant and often of greater magnitude,
are not always considered to be unjust. There
have been several proposed solutions, which vary
according to different theoretical interpretations
and explanations. At the global level, the most
plausible thesis has focused on improving global
governance mechanisms. While that latter are attractive and have some arguments in their favor,
they are insufficient because they do not incorporate an understanding of how the historical process of the constitution of the nations occurred and
the importance of the position of each country in
the global productive system.
Key words Health inequalities, Social determinants of health, Social inequity, Global health
Mauricio Lima Barreto 1
DOI: 10.1590/1413-81232017227.02742017
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Human society, which comprises the more than
seven billion individuals who inhabit the planet,
presents clear divisions in a number of important aspects. Spatially, it is divided into continents
and nations with different demographic and geographical characteristics. There are differences
in levels of development and wealth, as well as
phenotypic and cultural differences, which include a diverse set of ethnicities. Many of these
divisions are the result of adaptive, geographical and climatic processes, some are the result
of eventual phenomena, and others derive from
complex historical, social, economic and cultural
processes. Some of these divisions, which could
be merely differences (e.g. men and women) become inequalities, and very often iniquities, insofar as they define relationships that are essentially based on power and the access to, and the
possession of, goods, services and wealth. Consequently, the fruit of collective work that has been
accumulated over generations is often unequally
These inequalities are often transferred into
the field of health: they are visible in the unequal
health conditions of different groups, in the levels of health risks to which these groups are exposed, and also in terms of differential access to
the resources available in the health system. It is
no coincidence that most of the inequalities observed in the area of health are directly related to
inequalities observed in other levels of social life3-
. Health inequalities generate unequal possibilities in relation to the ability to take advantage of
scientific and technological advances in this area,
different chances of exposure to the factors that
determine health and disease, as well as different
chances in relation to illness and death. In the
same way that social inequalities have persisted
in all countries, regardless of their level of development, health inequalities persist in the same
In the current international context, with
nation states involved in the process of economic globalization, discussions about inequalities
have highlighted inequalities within the same
nation and also inequalities between nations.
Inequalities between countries are related to the
differences in economic and social development
achieved by different countries, which are generated by the position that these countries have
occupied during different phases of history within the global productive system. The latter reflect
historical aspects, and the international economic and political environment in relation to each
country’s share of global resources and development opportunities6
Inequalities within a country relate to the distribution of accumulated wealth within a society,
and in particular how that society is organized
and the social relations and power established
among its various strata. It is defined by the
history and the political models that have been
adopted, and how the state has redistributed national wealth through fiscal and transfer systems,
which have generated greater or lesser distributive distances between existing social groups.
Cultural elements are also important in terms of
amplifying and consolidating some existing inequalities7
More recently, the concept of global inequality has arisen, which involves the combined effects
of these two types of inequalities8
. Global inequality is the result of inequalities both between
and within countries, and it is therefore defined
by the interaction of the determinants of each.
The availability of international data has made it
possible to conduct empirical studies regarding
the issue of global inequality. For example, when
the GINI index, which is one of the most frequently used methods to measure social inequality within a country, is calculated globally it results
in even higher levels than those found in nations
with the highest levels of social inequality. In recent years, the GINI indices of countries with the
highest levels of inequality have been around 0.60
(1 = maximum inequality and 0 = total equality), while the global GINI index is close to 0.70.
The global GINI index captures the extremes of
the poorest strata of the poorest countries and
the richest strata of the richest countries, which
translates into a higher level of inequality than
when measured in each country separately.
The aim of this article is to present health
inequalities as a global problem that affects the
populations of poor countries, but also those
of rich countries, and the continuation of these
inequalities demonstrates the historical and
structural roots of this problem. Although this
discussion is related to discussions about poverty and health, it has a different, more specific
dimension. Health inequalities are undoubtedly
one of the most relevant problems in the field of
population health and they represent a challenge
to those who seek to overcome them.
2099Ciência & Saúde Coletiva, 22(7):2097-2108, 2017
Determinants of health conditions
For many, health is understood as being restricted to biological factors; for others, it is a
complex phenomenon with multiple determinations that are based on the way people live
and are organized. For a long period these two
explanatory theories have formed the basis for
discussions, and they have competed to provide
plausible explanations about the health conditions of human populations9-11. The relevance of
this debate is that it defines the manner in which
societies organize themselves to solve their health
The former theory is based on the development of biomedical sciences and their explanations of the mechanisms of diseases, as well as
alternatives to correct them. It focuses on the
search for a detailed understanding of human biology in the expectation that this will provide the
necessary explanations to understand how human health disorders occur and how they can be
corrected. It supports technologies based on prevention, diagnosis, cure and rehabilitation, which
are available or being developed, and forms the
basis of what we now call a “modern” health system. The development of this system has been
accelerated by advances in biomedicine and resulting technologies, especially since the second
half of the twentieth century.
The latter theory precedes the development
of biomedicine and argues that there is accumulated evidence that changes in economic, social,
political, environmental, cultural or behavioral
contexts affect the health conditions of individuals and populations11-13. Conceptions about the
social determination of health and disease developed during the nineteenth century and they
were expressed in the works of important thinkers who were mainly located in Europe. These
pioneers established the idea that the health
conditions of populations are directly related to
the context in which they live, and the position
of individuals in the social pyramid. Of particular note are studies by Louis René Villermé14 in
France, Edwin Chadwick15 in England and Rudolf Virchow16 in Germany, all of whom provided seminal contributions to the theme of social
Because we live in an age when these two theories coexist, and biomedical sciences and health
services are both growing and strengthening, it
is evident that these theories are in competition
with each other. Health services, as they are currently organized, play an important role in curing and rehabilitating many of the pathological
processes that afflict individuals. For example,
prevention actions such as the use of vaccines
and screening methods for the early diagnosis
and reduction of damage from pathological processes are already available. However, they have
few resources to deal with the social and environmental determinants that are the source of many
of the health problems affecting individuals
and populations. With limited exceptions (vaccine-preventable diseases) there has been little
action regarding the incidence of health events.
This dispute has fueled a prolonged debate
regarding the importance of each of these theories in relation to the health conditions of human
populations. The most elaborate contribution
was by Thomas McKeown, who from 1950-1980
wrote an important body of scientific work which
argued that medical technology and the health
system played a secondary role in the important
and positive changes that occurred in the health
conditions of the English population from the
late nineteenth century until the second half of
the twentieth century17,18. McKeown argued that
these transformations could be explained by improvements in general living standards, especially in terms of diet and nutritional status, which
were the result of better economic conditions.
During this period great changes occurred in
several spheres of life, especially in the economic,
social, cultural and environmental fields, which
were the main explanatory factors for the significant improvements in the population’s health
conditions. As in the case of England, health conditions in many countries which are now developed also had their greatest turning point, for the
better, over the same period. For much of this period, most of the preventive, diagnostic or therapeutic resources for the diseases and health problems that exist today were not available. These
technologies were only invented in the 1930s and
they were only used in a large-scale in health systems from the 1940s19. This chronology is central
to McKeown’s thesis that the immense changes in
health conditions observed in the late nineteenth
and early twentieth centuries only minimally depended on biomedical technologies.
Although some of the arguments put forward
by McKeown have not been fully confirmed, especially his emphasis on the role of diet and nutrition, his argument about the secondary role
of biomedical technologies has had widespread
repercussions10,20. While health technologies have
had been intensely developed over the last decades, and some of them highly effectively, argu-
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ments about the importance of technologies and
the health system transforming the health conditions of populations have not been empirically
demonstrated. After the massive introduction
of biomedical technologies and the expansion
of health systems, this type of research has become subject to interpretative confusion. At the
moment that the two effects (social determinants
and biomedical technologies) became active
there were clear methodological difficulties in
separating the effect of each of them. However,
reinforcing the thesis of social determination, in
this same group of (developed) countries, despite
the advances in systems and levels of health that
have been observed, important differences persist in health conditions when their populations
are stratified by geographic areas or social or ethnic groups5
. In addition, periods of crisis are often accompanied by worsening health conditions
in the populations of these countries. For example, events such as the disintegration of the former Soviet Union, or the financial crisis of 2008
which led many European countries to economic
recession and the implementation of austerity
policies, were followed by worsening health conditions for their respective populations21.
The study of historical trends in the health
conditions of populations remains an important
source of evidence for the social determination of
health and disease, as well as health differentials
between countries. A research program that originated in the economic and demographic sciences has shown a strong relationship between the
economic development of countries and health22.
Although it initially focused on economic factors, this line of research was modified to include
the effects of different social factors and policies
(education, public health, etc.).
Social determinants: inequalities
and equity
As we have seen, since at least the nineteenth
century evidence has increased that the health
conditions of a population are related to the
characteristics of its social and environmental
context. Poverty, poor housing conditions, an
inadequate urban environment, and unhealthy
working conditions are factors that negatively affect the health conditions of a population. At the
end of the nineteenth century, biomedical sciences emerged and began to have an overwhelming
influence in providing explanations for health
problems and diseases, with social and environmental determinants being secondary. However,
biomedical theories have never adequately explained many phenomena within a population
(for example, the rich have better health conditions than the poor) or between populations in
different countries (for example, richer countries
have better health conditions than poorer countries).
With few exceptions, the occurrence of the
most diverse diseases and health problems is
aggravated for social groups living in socially disadvantaged situations, in other words, for
the poorest, ethnic minority groups or groups
that suffer any type of discrimination. It is not
by chance that poor countries have worse health
conditions compared to rich countries. Likewise,
in any given country, whether rich or poor, the
poorest regions and the poorest or marginalized
ethnic groups consistently have worse health
conditions. Further evidence is provided by the
fact that when policies which improve economic conditions or strengthen social protection are
implemented in any of these countries they have
positive impacts on health conditions.
A recent and very important landmark that
highlighted the persistence of health inequalities
in developed countries was the so-called “Black
Report” in the United Kingdom23. In 1977, the
Health Minister of a socialist government appointed a commission led by Douglas Black, who
was then president of the Royal College of Physicians, to analyze the existence of health inequalities. This action was taken because the national
health system in the UK (NHS), which had been
created in the 1940s, was founded on the principles of fairness and universal accessibility. One
of the relevant observations of this commission
was that in the period since the establishment of
the NHS there had been major improvements in
the health conditions of the British population,
regardless of social class (actually occupational
class). But the most unexpected finding was that
the differentials of health levels between social
classes had persisted, and in relation to some
problems they had actually widened. Furthermore, inequalities persisted regarding the availability and use of health services. These results
were presented in 1979, when the British government was then led by the Conservative party,
which not only resisted its publication but also
made explicit its non-commitment to the results
and recommendations in the prologue of the
report. Nevertheless, this document had an immense impact on subsequent discussions regarding health inequalities in developed countries. In
terms of academic research it rekindled interest
2101Ciência & Saúde Coletiva, 22(7):2097-2108, 2017
in research on inequalities in health, and in the
field of politics it stimulated actions by governments regarding this dimension of inequalities.
The report explained important moral issues
experienced by these societies. It exposed a cruel
aspect of capitalism, even at the advanced stages
that it had reached in these countries, at a time
when these societies would have been expected
to be reasonably just in relation to their citizens.
At this point it is important to establish the
differences between inequalities and inequities
in health24,25. Inequalities refer to perceived and
measurable differences that exist in health conditions, or are related to differences in the access
to prevention, cure or rehabilitation of health
(inequalities in health care). Health inequities,
on the other hand, refer to inequalities that are
considered to be unjust or that stem from some
form of injustice. It reflects on a society how it
translates existing inequalities and differentiates
them into just or unjust ones, and this translation
varies among societies. In many societies, huge
differentials in health levels between individuals
at the top or bottom of the social pyramid are
not perceived as being unjust. This can happen
in developed, poor, or developing countries.
Conversely, in other societies relatively small differences in health levels can be translated into a
strong public perception of inequity. This happens, for example, in some Scandinavian countries. This issue is important because although
inequalities are the subject of discussions in the
scientific field and several methods have been
developed to measure them, which facilitates
comparative studies of health inequalities both
within and between societies, it is more difficult
to objectively measure inequities because they
translate the way that societies perceive and interpret these inequalities, even though it extremely
important to understand them. The conditions
for formulating concrete political actions aimed
at minimizing existing inequalities emerge at the
moment when inequalities become iniquities.
In recent decades, the growth of the neoliberal perspective and individualism has strengthened the belief that events within society are the
responsibility of the individuals who suffer them,
minimizing the view of society as a social and
collective phenomenon. This perception of the
world has been the foundation for influential political forces to interpret inequalities as the fruit
of individual problems and to deny that they are
an expression of injustice, leading to the argument that there is therefore no need for government policies and actions to minimize them.
However, the issue of social inequalities in
health has grown within intellectual and academic debates in recent decades around the
world. The availability of data from a variety of
sources has uncovered and provided new evidence regarding the extent of health inequalities
and, furthermore, shown that in many contexts
they are increasing. A few countries (especially
in Europe) have used this evidence to introduce
actions based on social determinants into their
health policies and to partially reduce inequalities; however, the vast majority have not placed
this issue among their political priorities.
At the international level, the importance
of social determinants of health became more
prominent at the time of the creation of the World
Health Organization (WHO) Commission on
Social Determinants of Health. This high-level
commission was created by the Director-General
of the WHO in 2005 with the mission to organize the evidence regarding the actions necessary
to promote equity in health at the global level.
In its final report, which was published in 2008
with the provocative title of “Closing the gap in
a generation”26, after a thorough analysis of the
evidence of the importance of social inequalities
in health in determining many health problems
the Commission called on the WHO and all
world governments to work towards reducing
all forms of health inequalities26. The Commission synthesized its recommendations into three
central points: 1) to improve daily living conditions; 2) to combat the unequal distribution of
power, money and resources; and 3) to measure
the magnitude of the problem and evaluate the
impact of actions. The Commission’s report was
followed in 2011 by the 1st World Conference on
the Social Determinants of Health, which was
convened by the WHO and held in the city of
Rio de Janeiro, Brazil with the participation of
delegates from 125 different countries. The main
output of the conference was the Rio Political
Declaration on Social Determinants of Health, in
which delegates affirmed their “determination to
promote social equity and health through actions
on the social determinants of health and well-being implemented through a broad intersectoral
Theories that seek to explain
health inequalities
Studies about health inequality which start
from different theoretical foundations in terms
of their empirical investigations offer different
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interpretations and solutions in relation to the
problem. Although they have tended to focus
primarily on explaining inequalities among social groups within the same nation, similar theoretical foundations can serve as a basis to interpret inequalities between nations and also global
inequalities. To summarize, it is possible to state
that these theories are organized into two types
of explanations; one based on individuals and
another based on structural explanations5,28.
The explanations based on individuals are
very popular among Anglo-Saxon authors; however, they are grouped into different tendencies
and those that stand out are as follows: those that
focus on the material dimensions of life, especially regarding the form in which the wealth of society is distributed among its members; those that
focus on cultural-behavioral dimensions (lifestyles); and those that emphasize psychosocial
dimensions, i.e. how individuals interpret their
position in the social hierarchy and the links between this perception and subsequent biological
phenomena (e.g. stress mechanisms), with their
potential pathogenic effects. The psychosocial
theory originated in the 1960s and 1970s through
the works of John Cassel29,30. However, another line of study, initiated by Richard Wilkinson,
constituted a new and interesting evolution of
the original theory31,32. Wilkinson developed the
idea that inequalities not only determine differences in the material world, and therefore explain
pathologies related to various deficiencies (e.g.
famine, poor housing or sanitation conditions,
and insufficient income to cover the costs of rearing children), but that inequalities themselves
generate complex psychosocial phenomena that
are expressed in pathogenic phenomena, in other
words, social inequalities have pathogenic properties. This concept was subsequently expanded
to (partially) explain existing inequalities among
other forms of stratification and discrimination,
such as, for example, between genders and ethnicities33.
The structural explanations focus on the idea
that the social determinants which generate inequalities in health are shaped by determinants
that exist within the superstructure of society, i.e.
politics, productive organization, etc. The political definitions that organize the state will also
result in political options that will either favor or
reduce health inequalities. Reinforcing this theory, and providing contrary evidence to those who
still believe in distributive possibilities and the
consequent reduction of inequalities within the
capitalist framework, recent empirical evidence
from a study by Piketty34 shows that capitalist accumulation tends to be differential. It is greater
between favoring those who have already accumulated, which results in the expansion of social
inequalities. This tendency can be contained or
mitigated by distributive policies, when they are
eventually adopted.
New scenarios regarding social inequalities
in health
In a world undergoing intense transformations, some social processes are amplified by the
process of globalization and they grow in importance because of their implications for health
inequalities. Due to their current relevance and
their implications in relation to health inequalities, the following two aspects will be now be
highlighted: urbanization and migration.
Urbanization and the importance of cities
In 2014, 54% of the world population lived
in urban areas. In 1950, this percentage was only
30% and it is estimated that in 2050 this percentage will exceed 70%. The highest rates of urbanization are in North America (82% of the population) and the lowest are in Africa (40% of the
population). Latin America and the Caribbean
have high urbanization rates, with 80% of their
population concentrated in urban areas, rates
that are close to that of North America35.
This intense growth in urbanization was due
to the massive transfer of the rural population to
urban areas. The definition of urban can range
from agglomerations with a few thousand inhabitants to megacities with several million inhabitants. In relatively restricted areas these centers
group together a large number of people. These
agglomerations create a series of problems and
challenges which have repercussions in the health
sphere; there tends to be an unequal and unfair
distribution of space between social groups.
The patterns of inequalities that already exist in societies are reflected within these restricted spaces and it is possible to clearly see the ills
that are generated by social inequalities and their
deleterious effects on human health. In the nineteenth century, Villermé showed how the social
and environmental differences between different
neighborhoods in Paris were reflected in unequal
mortality rates14 and these inequalities, although
on a smaller scale and with less visibility, persist
to the present day36. In many poor and developing countries with high levels of social inequal-
2103Ciência & Saúde Coletiva, 22(7):2097-2108, 2017
ities, urbanization becomes synonymous with
inequality and exclusion in all its forms.
Migrations and the limits of human
Since time immemorial, sectors of populations or even whole populations have moved to
new destinations for various reasons. In 2013,
it was estimated that 232 million people – 3.2%
of the world’s population – lived outside their
country of birth, and another 700 million were
internal migrants in their own country of birth35.
The patterns and motives for these migratory
movements have changed greatly over time; however, it is clear that the majority of migrants who
cross national borders do so in search of better
economic and social opportunities. In recent decades, exacerbated disparities between nations,
global economic expansion, geopolitical transformations, wars, ecological disasters and many
other occurrences have had, and will continue to
have, a profound impact on people’s decisions to
move to other nations. The recent phenomenon
of the massive migration from some Arab countries to Europe is an example of the explosive and
uncontrolled possibilities that the migratory issue can generate (
The migratory issue introduces an important
point into the debate on inequalities. Estimates
show that social inequalities between countries
account for a larger share of global inequalities
than inequalities within countries. While inequalities within nations are much more related
to class issues and other processes of social stratification, inequality between nations raises the issue of place of birth, or what has been termed the
“citizenship prize”, which is related to history and
the overall process of development of nations6,7.
Returning to the question of life expectancy
mentioned above, a child born in Sierra Leone
in 1990 only had an average life expectancy of 38
years, which was less than a child born in Japan in
the same year (46 years compared with 84 years).
Therefore, the issue of where one is born takes
on great importance, and the migratory movement is defined by this attempt to change what
was to some extent established by one’s place and
moment of birth. However, in a globalized world,
in which capital, commodities and human beings circulate, there are serious limitations on the
movement of people, especially when they wish
to move between nations.
Global health conditions:
the expansion of inequalities
At the global level, indicators of the health
conditions of populations generally show positive trends. However, more detailed observations of the existing evidence demonstrate that
this picture is much more dynamic, with the
persistence of health problems or diseases that
should have been eradicated or controlled and
the emergence of unexpected health problems
or diseases. In fact, inequalities in the level of
health persist and, in many cases, have increased
between nations or between regions and social or
ethnic groups within the same nation.
A brief summary of inequalities
between nations
An estimated 800 million people worldwide
are chronically hungry. One in six children in
developing countries is underweight, and more
than one-third of deaths among children under
five are attributable to malnutrition37. Insufficient access to safe and nutritious food exists
despite the fact that global food production is
sufficient to cover 120% of global dietary needs.
Life expectancy at birth is an important
marker of health conditions and the chances of
survival for a population. On the global average,
the life expectancy at birth of an individual in
1990 was 64 years; in 2013 that number had increased by seven years to 71 years. However, as
averages these values conceal a series of inequalities. For example, in 2013 the average life expectancy at birth in countries ranged from a minimum of 46 years (38 in 1990) in Sierra Leone, to
84 (79 in 1990) in Japan. By 2013, life expectancy
had increased in both countries and although the
gap has narrowed slightly (from 41 to 38 years)
they are still at unacceptable levels38.
Children are especially sensitive to social and
environmental adversities. Despite advances in
recent decades, it is estimated that 6.3 million
children under the age of five died in 2013, mostly due to preventable causes in poor or developing countries. Children in sub-Saharan Africa
are 15 times more likely to die before their fifth
birthday than children in the world’s developed
regions. In 2015, the highest mortality rate was
observed in Afghanistan (115 deaths per 1,000
live births) and the lowest was in Monaco (1.8
deaths per 1,000 live births)39. From 1990, when
the Millennium Development Goals were established, to 2015 the global infant mortality rate fell
2104 Barreto ML
from 62 to 32 deaths per 1,000 live births. Despite this substantial reduction (around 50%) the
established target was not reached, which was to
reduce the 1990 rate by two-thirds.
Today, infectious diseases continue to be the
leading cause of death for children and they are
also a major cause of death in adults. Globally,
three of the top ten causes of death are infectious
diseases. These also account for 16% of deaths
each year. Most of these deaths occur in poor and
developing countries and they are attributable to
preventable or treatable diseases such as diarrhea,
respiratory infections, HIV/AIDS, tuberculosis
and malaria. Although there have been significant advances in interventions to prevent and
treat most of these diseases, such interventions
are not always available for the populations that
need them. Taking the example of tuberculosis,
which is a disease highly linked to the conditions
in which afflicted populations live and whose occurrence changes rapidly when these conditions
change, in 2013 it was estimated that nine million
people became sick with tuberculosis worldwide,
with most of these cases (56%) occurring in
Southeast Asia and the Western Pacific. However,
Africa had the highest incidence of tuberculosis,
with 280 cases per 100,000 inhabitants. Of these
cases, around 500,000 were caused by multi-drug
resistant tuberculosis (MDR-TB) bacilli, which,
in addition to causing more severe diseases, often
increase treatment costs, making them prohibitive for the majority of patients living in poverty. In the same year, the estimated total number
of deaths from tuberculosis was 1.5 million. Of
these deaths, more than 95% occurred in developing countries, although the death rate fell by
45% between 1990 and 201340.
Non-communicable chronic diseases
(NCDs) as a whole are responsible for a significant proportion of the world’s burden of diseases, accounting for almost two-thirds of global
deaths (36 of the 57 million deaths in 2008). The
main health problems in this group are cardiovascular diseases, cancers, chronic respiratory
diseases (such as COPD and asthma) and diabetes. Although other diseases, such as mental and
neurological diseases (including various forms
of dementia), contribute to the high burden of
morbidity (lower mortality), they have not been
prioritized in global plans. NCDs are increasing rapidly in developing countries, where they
impose large-scale human, social and economic
costs, many of which could be avoided with wellknown, cost-effective and feasible interventions.
Although they were initially associated with
wealth, evidence shows that about 80% of NCD
deaths occur in developing countries. Even in
sub-Saharan nations, where communicable diseases, maternal and perinatal issues, and nutritional deficiencies are still more important when
taken together, they are in decline, whereas cases
of NCDs are growing rapidly. This picture has resulted in projections that by 2030 NCDs will be
the most frequent cause of death on the African
It is estimated that more than five million
(9%) of deaths occurring globally are related to
various forms of violence. Approximately a quarter of these deaths result from suicide and homicide, and traffic accidents are responsible for another quarter. The various types of violence vary
in different regions of the world, but, in general,
their rates are always higher in poor and developing countries42.
The growth in health inequalities:
possible solutions
The construction of a more equitable world
has been the aspiration of different political
movements which understand that reducing inequalities in the various spheres of human life is
essential and guarantees the existence and sustainability of human society. Health inequalities
expose one of the facets of inequalities that are
prevalent among human beings, the cruel and
damaging effects on one’s own existence, which
is reflected in the immense differences in life expectancy or the burden of disease and suffering.
The evidence of the importance of social determinants in explaining health inequalities is
compelling. However, although there are clear
academic and political arguments that favor the
implementation of actions to redress the determinants of health inequalities, policies to mitigate these inequalities have been scarcely implemented as part of the public policies of national
governments, and still less to alleviate inequalities between nations. There are several reasons
for this lack of political motivation; however,
some aspects have been recurrent in the literature
regarding health inequalities.
One of the first aspects to consider is the consolidation of a health system based on biomedical knowledge and the resulting technologies, together with strong industrial and service sectors.
These forces tend to generate and consolidate
health systems that are only slightly affected in
conceptual and structural terms, or favor actions
directed at the social determinants of health.
2105Ciência & Saúde Coletiva, 22(7):2097-2108, 2017
The conceptual, moral, and political differences that exist in relation to the inequalities
between social groups within the same nation
and the inequalities between different nations
have to be considered. The former is more often
understood as being iniquitous than the latter.
For example, this is explicit in the work of the
influential moral philosopher John Rawls. In The
Theory of Justice42 Rawls establishes the principles
of justice that should be established between individuals and groups within the same society; he
does not consider this relevant when the question refers to inequalities between nations43. With
regard to social inequalities in health, something
similar also occurs. The research and literature on
health inequalities predominantly focuses on inequalities between social groups within the same
nation. Comparisons between nations (or other
types of territorial organizations) have been relevant in some research, such as that developed
by Wilkinson, which demonstrates the centrality
of the levels of social inequalities of countries in
relation to the health conditions of their populations31,32. However, some scholars continue to argue that social inequalities in health are restricted
to groups of individuals within the same society5
These scholars claim that the research program
established by Wilkinson and others is “social
ecology” rather than relating to health inequalities.
Another aspect is that interventions regarding the social determinants of health require coordinated action in relation to various aspects
of the life of societies, which in governmental
terms implies multisectoral actions. The latter,
even when they are desired, are always difficult
to coordinate and implement from the political
and technical points of view. Nevertheless, efforts
to overcome this issue have been forthcoming.
The most advanced initiative to overcome this
dilemma has emerged in some European countries, where the most recent action in the field
of health inequalities has been the creation and
implementation of the concept of “health in all
policies”44. This strategy aims to include health
considerations in the formulation of policies in
different sectors such as labor, agriculture and
land use, housing, public safety, education, transportation, social protection, etc.
In the wake of the repercussions of the “Black
Report”23 and other important studies that have
followed, some developed (mainly European)
countries have experimented with coordinated
government actions in the field of health inequalities25. All these countries have information
systems and analysts capable of interpreting existing levels of health inequalities, but only a few,
generally among those with the lowest levels of
inequalities, have implemented policies focused
on reducing health inequalities. This observation
draws attention to the important discussion involving inequalities and inequities. The existence
of inequalities, and their magnitude, does not
immediately result in moral imperatives or generate political actions within a society. In some
societies, relatively small levels of health inequalities have generated strong policy actions to reduce them (e.g. some Scandinavian countries),
while others, with broad levels of health inequality, are not motivated to alleviate them (e.g. some
Latin American countries).
In poor and developing countries, where
health inequalities are of the highest magnitude,
there are few examples of the latter being among
the priorities of public policy. For example, following the establishment by the WHO of its
Commission on Social Determinants of Health,
Brazil, which is a country with immense social
and health inequalities, created its own national
commission45. However, after two years of work
this commission produced a report which, in the
main, was not assimilated into government actions46. Nevertheless, over the last two decades the
implementation in many developing countries of
redistributive policies such as income-transfer
and micro-credits47, which are non-health policies, have had positive effects on health inequalities48.
With regard to inequalities between countries, the proposals and actions have been even
more timid. For example, the final report of the
WHO Commission on Social Determinants of
Health26 places great emphasis on inequalities
within a particular society and less on inequalities between nations. It has a chapter dedicated to
the issue of health inequalities in the global sense,
which focuses on the need to strengthen so-called
“global governance” and explains the need for
coordination among various intergovernmental
agencies. Some of these ideas were subsequently
deployed in actions, such as the Millennium Development Goals (MDGs), which focused on the
eradication of extreme poverty from 2000-2015
and their successor, the Sustainable Development
Goals (SDGs), which include the additional aspiration of sustainable development in its three
forms (economic, social and environmental)
during the period 2016-2030.
More recently, another group (The Lancet,
University of Oslo Commission on Global Gov-
2106 Barreto ML
ernance for Health)49 has made advances in understanding and proposing actions in relation
to global inequalities. The latest document produced by this group entitled “The Political Origins of Health Inequity: prospects for change”
is intended to convey a strong message to the international community and to all actors who influence global governance processes: we must no
longer simply consider health to be a biomedical,
technical issue; we recognize the need for multisectoral and global actions and justice to address
health inequalities49.
In conclusion, although interest in the issue
of health inequalities has increased from the academic point of view, this interest has only had
a limited impact on public policies aimed at
improving the health of populations. Social inequalities in health are a global problem that, to
a greater or lesser extent, affects all human societies. They are mainly due to the inequalities that
exist between the different social groups in each
society. Although the inequalities that exist between different societies and nations are relevant,
and are often of a greater magnitude, they are not
always considered to be unjust, and as such they
are subject to political actions. The most plausible theory that has been put forward to solve the
latter type of inequalities has been to improve the
mechanisms of global governance, insofar as this
includes an understanding of how nations were
historically founded and the effect of the position
of each country in the global productive system6
2107Ciência & Saúde Coletiva, 22(7):2097-2108, 2017
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Chadwick. Cambridge: Cambridge University Press;
16. Taylor R, Rieger A. Medicine as Social Science: Rudolf
Virchow on the Typhus Epidemic in Upper Silesia. Int J
Health Serv 1985; 15(4):547-559
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nemesis? London: Basil Blackwell; 1979.
18. McKeown T. The Origins of Human Disease. Oxford:
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19. Bynum WF. The Western Medical Tradition: 1800 to
2000. Cambridge: Cambridge University Press; 2006.
20. Colgrove J. The McKeown Thesis: A Historical Controversy and Its Enduring Influence. Am J Public Health
2002; 92(5):725-729.
21. Stuckler D, Basu S. The body economics: Why austerity
kills. New York: Basic Books; 2013.
22. Preston SH. The Changing Relation between Mortality
and Level of Economic Development. Population Studies 1975; 29(2):231-248.
23. Department of Health and Social Security. Inequalities
in health: report of a research working group. London:
DHSS; 1980.
24. Kawachi I, Subramanian S, Almeida-Filho N. A glossary for health inequalities. J Epidemiol Community
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Tackling health inequalities: Lessons from international
experiences. Toronto: Canadian Scholars’ Press; 2012. p.
26. WHO Commission on Social Determinants of Health,
World Health Organization (WHO). Closing the Gap in
a Generation: Health Equity Through Action on the Social Determinants of Health: Commission on Social Determinants of Health Final Report. Geneva: WHO; 2008.
27. World Conference on Social Determinants of Health.
Rio Political Declaration on Social Determinants of
Health. Rio de Janeiro: WHO; 2011.
28. Smith KE, Hill S, Bambra C, editors. Health Inequalities: Critical Perspectives. Oxford: Oxford University
Press; 2016
29. Cassel J. The contribution of the social environment to
host resistance: the Fourth Wade Hampton Frost Lecture. Am J Epidemiol 1976; 104(2):107-123.
30. Cassel J. Psychosocial processes and “stress”: theoretical
formulation. Int J Health Serv 1974; 4(3):471-482.
31. Wilkinson R. Unhealthy societies: the afflictions of inequality. London: Routledge; 1996.
32. Wilkinson RG, Pickett KE. The spirit level: why more
equal societies almost always do better. London: Allen
Lane; 2009.
33. Krieger N. Discrimination and health inequities. Int J
Health Services 2014; 44(4):643-710.
34. Piketty T. Capital in the twenty-first century. Cambridge: The Belknap Press; 2014.
35. United Nations (UN). Department of Economic and
Social Affairs. Population Division. Washington: UN;
36. Martin-Fernandez J, Grillo F, Parizot I, Caillavet F,
Chauvin P. Prevalence and socioeconomic and geographical inequalities of household food insecurity in
the Paris region, France, 2010. BMC Public Health 2013;
37. Food and Agriculture Organization (FAO). El estado
de la inseguridad alimentaria en el mundo 2014: Roma:
FAO; 2015.
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39. Requeijo JH, Bryce J, Barros AJ, Berman P, Bhutta Z,
Chopra M, Daelmans B, de Francisco A, Lawn J, Maliqi B, Mason E, Newby H, Presern C, Starrs A, Victora CG. Countdown to 2015 and beyond: fulfilling the
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45. Landmann-Szwarcwald C, Macinko J. A panorama of
health inequalities in Brazil. Int J Equity Health 2016;
46. Comissão Nacional sobre Determinantes Sociais da Saúde. As Causas Sociais das Iniqüidades
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Article submitted 28/8/2016
Approved 28/11/2016
Final version submitted 03/2/2017

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