Ethics, Equity & Disparities-- A Public Health Conundrum

1. Ethics, Equity & Disparities-- A Public Health Conundrum Charles N. Oberg, MD, MPH June 28, 2002

2. A $10 trillion economy--riches in the world $1 trillion spend on health care First in Health Technology First in Health Research 11th in children living in poverty 17th in low Birthweight rates 23rd in infant mortality rates 25th in protecting children from gun violence The Public Health Conundrum

3. The Journey from Helplessness... • At the turn of the century little could be done for preventable diseases. • Goya’s masterpiece of a physician and a child with Diphtheria.

4. …to Space age technologies. • Who could have imaged the advances we have witnessed in the last Century.

5. Health Disparities • A Health Disparity is a difference in health status that is persistent across sub-groups of a population. • Disparities can be by race, income, geography and/or culture, etc.

6. Disparities by Age Group • Maternity & Infancy • Prenatal Care--Low Birthweight--Infant Mortality • Childhood • Immunizations, Injuries, Dental • Adolescents • Obesity, Sexuality, Pregnancy & Parenthood

7. Ethical Framework for Assessing Health Disparities Ethics “Inequity” Access Quality Health Disparity

8. Health Care “Access” • “…the timely use of personal health services to achieve the best possible health outcome.” (Institute of Medicine, 1993) • Two main aspects of accessibility: • Socio-organizational attributes • Geographic accessibility (Aday & Andersen, 1974)

9. The Components of “Quality” • Scope of Services and Health Benefit Set • Recipient Choice • Patient Confidentiality • Quality Assurance • Portability

10. Health Care “Equity” • “Securing Access to Care--The Ethical Implications of Differences in the Availability of Health Services” • “…Society has an ethical obligation to ensure equitable access to health care for all.” • (The President’s Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research, 1983.)

11. Norman Daniels & Equity • Seminal work “Just Health Care” built upon the President’s Commission report. • Theoretical construct of “distributive justice” could be used to create a system that provided equitable access to care for all persons.

12. Barriers to Equitable Care • Financial • Family Income • Third Party Coverage; Both Private & Public • Uninsured/Underinsured • Non-Financial • Clinic locations, clinic hours, provider attitudes • Cultural Sensitivity & Competence

13. “Of all forms of inequity, injustice in health care is the most shocking and inhumane.” Martin Luther King, Jr..

14. “The fundamental problem is an economic, governmental, social, and religious system that undergrids inequity and creates injustice.” Dr. David Hilfiker

15. Social Justice & Disparities Social Equity of Care Economic Justice Justice Establish “Livable Wage” & Reduce Income Gap Elimination of Health Disparities Autonomy of our Citizens

16. An Ethical Matrix to Examine Disparities

17. Equitability of Care for All • “Health of Body and Mind is so fundamental to the good life, that if we believe men have any personal right at all as human beings, they have an absolute moral right to such a good measure of health as society and society alone is able to give them.” Aristotle 330 B.C.