Health inequalities are a growing problem worldwide

Global health inequalities are substantial, growing, and influenced by economic, social and health-sector variables as well as geography, a study concludes in the November issue of the Journal of Epidemiology and Community Health.

"Particularly disturbing findings from this study are that countries with high mortality in young children are making slow progress, gaps in adult mortality are becoming wider, and countries with the highest adult mortality have reversed their trend from mortality reduction," said lead author Jennifer Prah Ruger, assistant professor of public health in the Department of Epidemiology and Public Health at Yale School of Medicine.

This is the first systematic study of global inequalities in adult and child mortality to identify three distinct mortality groups--better off, worse-off and mid-level--using cluster analysis methods to reveal new associations and structure in data, and examine the underlying risk factors associated with inequality in mortality. "Unlike previous studies, this research focuses on gaps in health inequalities between countries," Ruger said.

The probability that a child will die before age five and an adult will die at an early age are disproportionately higher throughout sub-Saharan Africa and Afghanistan than in countries in any other geographic region, according to the study. The authors report that these countries have lower average incomes, more extreme poverty, higher inflation and less trade. They also have lower levels of investment in human and physical resources, more health risk factors and less effective disease prevention, and worse educational outcomes.

Ruger and co-author Hak Ju Kim, from the Department of Social Welfare, Gyeongsang National University, Jinju, South Korea, found that these countries have a four-fold higher percentage of people living on less than $1 per day; more than double the female illiteracy rate, less than one-sixth the gross national income in international dollars; and one-fifth the outpatient visits, hospital beds, and physicians as their low-mortality counterparts. The study also showed an even greater gap in total per capita expenditure on health care: a 20-fold difference in spending between countries with low and high adult mortality and a 50-fold difference in spending between countries with low and high under five-year old mortality.

"The AIDS epidemic is likely driving some of the gap in adult mortality," said Ruger. "We found that countries with high adult mortality rates had roughly 35 times the prevalence of HIV infection than the lowest mortality countries."

Ruger and Kim analyzed data from the World Development Indicators 2003 database over the past five decades, compiled by the World Bank. They emphasize that results from this study are particularly relevant for directing global health policy and multinational organizations like the World Bank, which work in multiple policy domains affecting health inequalities.

In an accompanying article, Ruger, who is also an assistant adjunct professor at Yale Law School, examines the ethical challenges posed by such inequalities for the global health community--why such inequalities are morally troubling and efforts to reduce them are morally justified, and how much priority disadvantaged groups should receive. Ruger asserts that ethical commitments are required for social organization and action for redistribution of resources, legislation and policy, public regulation and oversight, and the creation of public goods.

Ruger argues for shared health governance in correcting global health inequalities and places responsibility on state and international governments and institutions, along with non-governmental organizations, businesses, communities, families and individuals.

"Individual nation-states must assume a prior and direct role of responsibility," Ruger said. "Ethical principles have the power to motivate and hold global and national actors accountable for achieving common goals."

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Ruger is funded in part by a career development award from the National Institutes of Health.

Citation: Journal of Epidemiology and Community Health, 60: 928-936; 998-1003 (November 2006).


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