Starfield Barbara
Johns Hopkins School of Public Health, 624 North Broadway, Room 452, Baltimore, MD 21205 USA.
Dev World Bioeth. 2004 May;4(1):76-95. doi: 10.1111/j.1471-8731.2004.00068.x.
Developing strategies to reduce inequities in health requires an understanding of how inequities occur, determining the salient factors in their production, and deciding which ones are most amenable to change. The recognition of several principles regarding the manifestations and genesis of inequities can help to decide on strategies. In making decisions, it is important to consider whether the aim is to reduce disparities in the occurrence of ill health or to reduce disparities in the severity (including co-morbidity, disability, dysfunction and fatality) of ill health. Evidence shows that the major impact on equity of health services, particularly regarding their potential to reduce severity, is attributable to the strength of primary care resources and services in communities and countries. Virtually every influence on the genesis of inequities is determined by the political context in which policy is made. The issue of health services is not different in this regard from other types of strategies. There is no longer any doubt about the pervasive influence of social factors on health. Almost two centuries of descriptive research provides convincing evidence of associations between social structures and relationships and health status in all countries and in all societies; if there is anything new from more recent research, it is that the association is not limited to differences between the lowest social strata and other social strata. Rather, the association is noted throughout the social spectrum. That is, there is a social gradient in health such that, for many if not most manifestations of ill health, the lower the social stratum, the worse the health. The challenge for the future is to understand why this is the case, to create a consensus that these inequalities are unnecessary and unacceptable, and to devise strategies that are both effective and possible. This paper will focus on the first of these aims, in a context that facilitates attention to the second and third aims.
制定减少健康不平等的策略需要了解不平等现象是如何产生的，确定其产生过程中的显著因素，并决定哪些因素最易于改变。认识到一些关于不平等现象的表现形式和成因的原则有助于确定策略。在做决策时，重要的是要考虑目标是减少健康不良发生率方面的差距，还是减少健康不良严重程度（包括合并症、残疾、功能障碍和死亡率）方面的差距。有证据表明，卫生服务对公平性的主要影响，尤其是在其降低严重程度的潜力方面，可归因于社区和国家初级保健资源和服务的力度。几乎对不平等现象成因的每一种影响都取决于制定政策时的政治背景。在这方面，卫生服务问题与其他类型的策略并无不同。社会因素对健康的普遍影响已不再有任何疑问。近两个世纪的描述性研究提供了令人信服的证据，表明所有国家和社会中社会结构与关系和健康状况之间存在关联；如果说最近的研究有什么新发现的话，那就是这种关联并不局限于社会最底层与其他社会阶层之间的差异。相反，这种关联在整个社会范围内都有体现。也就是说，健康存在社会梯度，即对于许多（如果不是大多数）健康不良表现而言，则社会阶层越低，健康状况越差。未来的挑战在于理解为何会出现这种情况，形成一种共识，即这些不平等是不必要且不可接受的，并制定出既有效又可行的策略。本文将在有助于关注第二和第三个目标的背景下，聚焦于这些目标中的第一个目标。
