messages and channels to ob-servable social and bebavioralcharacteristics of a culture, forexample, familiar people, foods,music, language, and places. Itmay be more important to ad-dress deep structure, which re-flects the cultural, social, psycho-logical, environmental, andhistoriccd factors that affecthecJth for a minority community.Resnicow and Braithwaite arguethat when health communica-tion appropriately addresses sur-face structure, it increases recep-tivity to and acceptance of thecampaign, but when it also ad-dresses deep structure, it con-veys true salience to the commu-nity it seeks to reach. Clearly,there is much to learn about cre-ating health communication in-terventions that appreciate thecomplexity of culture, and thenevaluating the impact of suchprograms on eliminating healthdisparities.

Eliminating health disparitiesrequires that public health pro-fessionals expand their use ofhealth communication strategiesin comprehensive interventionsaimed at effecting individual,community, organizational, andpolicy change. Such interven-tions can effectively address the

multiple determinants of healththat underlie disparities. How-ever, to design effective interven-tions, we must understand thecomplexity of culture and inte-grate cultural factors into ourhealth communication efforts.Furthermore, we must work col-laboratively with communitiesexperiencing disparities to over-come the historical context ofdistrust and create meaningful,effective health communicationinterventions.

Vicki S. Freimuth, PhD,Sandra Crouse Quinn, PhD

About the AuthorsVicki S. Freimuth is with the Departmentof Speech Communication and the CradySchool of Journalism, University of Geor-gia, Athens. Sandra Crouse Quinn is withthe Graduate School of Public Health, Uni-versity of Pittsburgh, Pittsburgh, Pa.

Requests for reprints should be sent toSandra Crouse Quinn, PhD, 230 ParranHall, 130 DeSoto St, Pittsburgh, PA15261 (e-mail: squinn@pitt.edu).

This editorial was accepted August 24,2004.

AcknowledgmentsS. C. Quinn is supported in part by theCenters for Disease Control and Pre-vention and the Association of Schoolsof Public Health (cooperative agree-ment S2136-21/21CDC/ASPH). She isalso supported by the EXPORT Health

Project at the Center for MinorityHealth, Graduate School of PublicHealth, University of Pittsburgh (grantP60 MD-000-207-02 from the Na-tional Center on Minority Health andHealth Disparities, National Institutes ofHealth).

References1. Making Health Communication Pro-grams Work. Bethesda, Md: NationalCancer Institute; 2001.

2. Freimuth V, Cole G, Kirby S. Issuesin evaluating mass media heaith com-munication campaigns. In: Rootman I,Goodstadt M, Brian Hyndman, et al.,eds. Evaluation in Health Promotion:Principles and Perspectives. Copenhagen,Denmark: WHO Regional Office for Eu-rope; 2001:475-492.

3. Healthy People 2010: Understand-ing and Improving Health. Washington,DC: US Dept of Health and HumanServices, Office of Disease Preventionand Health Promotion; 2000.

4. Office of Communication, Centers forDisease Control and Prevention. Entertain-ment Education: Overview. Available athttp://www.cdc.gov/communication/surveys/surv2001.htm. Accessed July21, 2004.

5. Institute of Medicine. The Future ofthe Public's Health in the 21st Century.Washington, DC: National AcademiesPress, 2003.

6. Street RL Jr, Rimal RN. Healthpromotion and interactive technology:A conceptual foundation. In: Street RLJr, Gold WR, Manning T, eds. HealthPromotion and Interactive Technology.Mahwah, NJ: Lawrence Erlbaum Associ-ates Inc; 1997:1-18.

7. Hawkins RP. Pingi'ee S, GustafsonDH, et al. Aiding those facing health

crises: the experience of the CHESSproject. In: Street RL Jr, Gold WR, Man-ning T, eds. Health Promotion and Inter-active Technology. Mahwah, NJ:Lawrence Erlbaum Associates Inc;1997:79-102.

8. Van Ryn M, Fu S. Paved with goodintentions: do public health and humanservice providers contribute to racial/ethnic disparities in health? Am f PublicHealth. 2003;93:248-255.

9. Ashton C. Haidet P, Patemiti D, etal. Racial and ethnic disparities in theuse of health services: bias, preferencesor poor communication? / Gen IntemMed 2003;18:146-152.

10. Albrecht T, Goldsmith D. Socialsupport, social networks, and health.In: Thompson T, Dorsey A, Miller K,Parrott R, eds. Handbook of HealthCommunication. Mahwah, NJ: LawrenceErlbaum Associates Inc; 2003:263-284.

11. Roschelle A. No More Kin: Explor-ing Race, Class, and Gender in FamilyNetworks. Thousand Oaks, Calif: SagePublications; 1997

12. Cline R. Everyday interpersonalcommunication and health. In: Thomp-son T, Dorsey A, Miller K, Parrott R,eds. Handbook of Health Communication.Mahwah, NJ; Lawrence Erlbaum Associ-ates Inc; 2003:285-318.

13. Institute of Medicine.Health: Assessing Health CommunicationStrategies for Diverse Populations. Wash-ington, DC: National Academies Press;2002.

14. Resnicow K, Braithwaite R. Cul-tural sensitivity in public health. InBraithwaite R, Taylor S, eds. Health Is-sues in the Black Community. 2nd ed.San Francisco, Calif: Jossey-Bass; 2001:516-542.

ConfrontingHealthInequity:The GlobalDimension

Since the days of Hippocrates,health inequities and the role ofsodal and environmental factors inthe determination of marked dif-ferences in health status have beenwell recognized. For some timenow, the driving force behind pub-lic health has been understandingand intervening in the underlyingcauses of health inequity. The pub-lication of the Black Report' in theUnited Kingdom in 1980 broughta more focused approach to thisdiscourse by identifying specificfactors, such as social class, gender.

and race/ethnidty, as the socialand economic determinants ofhealth inequities. With this evolu-tion came a conceptual and opera-tional distinction between healthdisparities/inequalities and healthinequity/equity.^

These distinctions aside, theissue of health inequity has movedbeyond the academic discourseinto the arena of policy and ac-tion. In the United States, the2002 Institute of Medicine reportUnequal Treatment: ConfrontingHealth Care Disparities marked a

turning point^ It is, however, im-portant to recognize that like theproblem of health inequity itself,the struggle to conlront it is nei-ther unique to the United Statesnor simply a local matter Manynations, both developed and de-veloping, have adopted strategiesto reduce health inequities.

EFFORTS IN THEDEVELOPED WORLD

Confronting health inequitiesis increasingly a priority for

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health policymakers, both na-tionally and internationally.There are several recent exam-ples of national governments indeveloped countries undertak-ing major initiatives to reducehealth inequities. For instance,in the United Kingdom one ofthe first decisions of the incom-ing Labor government in 1997was to commission the "Inde-pendent Inquiry into Inequali-ties in Health." Under the direc-tion of Sir Donald Acheson, thecommission's mandate was toestablish the facts and suggestwhy, despite the increase inprosperity and substantial re-ductions in mortality evinced inthe United Kingdom in the pre-vious 2 decades, the gap inhealth status between those atthe top and bottom of the socialscale, as well as between variousethnic groups and between thesexes, had continued to widen."*On the basis of the commission'srecommendations, the govern-ment formulated a comprehen-sive plan that recognizes thestructural determinants ofhealth, such as the social envi-ronment and the wider commu-nity, with the overarching goalof reducing avoidable healthdisparities.^*'

In 1998, the EURO Healthfor All policy (Health 21) waspublished.' This policy specifiesthat by 2020 the health gap be-tween countries and betweensocioeconomic groups withincountries should be reduced byat least one fourth in all mem-ber states. Since that time, otherEuropean countries have under-taken similar comprehensive re-views and action plans at re-gional, national, and locallevels."'' The following EUROHealth for All policy recommen-dations are being implemented,at least partially, in member

states of the European Unionand various other neighboringcountries, providing a usefulmodel for similar action inother regions'":

1. Establish national health in-equity targets by identifyingand advocating relevant na-tional and regional health tar-gets and by tackling health de-terminants to reduce healthinequalities.2. Integrate health determinantsinto other policy areas at na-tional, regional, and local levels,using cross-sectoral approaches.3. Work at the local level bysupporting community develop-ment approaches and the inte-gration of local services, multi-disciplinary approaches, andpartnerships.4. Reduce barriers to ensureaccess to and use of effectivehealth care and prevention ser-vices by socially disadvantagedand vulnerable groups.5. Develop indicators and sys-tems for monitoring health in-equalities, including systems forcollecting data on structural fac-tors and determinants of health,such as social class, gender, andethnicity.6. Assess health impact by de-veloping and applying proce-dures, methods, and tools bywhich policies, programs, andprojects may be judged as totheir potential effects on thehealth of a population and thedistribution of those effectswithin the population.7. Evaluate financial and humanresources to ensure sufficiencyand to increase knowledge onhow to effectively tackle healthinequities.8. Create and support opportuni-ties to disseminate models ofgood practice and evidence-basedapproaches to tackle health in-

equalities, including databases ofsuccessful interventions.

Other developed countries,such as Australia, New Zealand,and Canada, are also in the pro-cess of incorporating health eq-uity and social determinants ofhealth into regional or nationalpublic health policies.""'^

In the United States in 1998,the Clinton administration estab-lished the Initiative to EliminateRacial and Ethnic Disparities inHealth, which set a nationalgoal of eliminating longstandingracial/ethnic disparities in healthstatus by 2010 and, for the firsttime, set high national goals forall Americans, ending a practiceof separate, lower goals for racialand ethnic minorities.''' Thereare mounting public and privatecoalition efforts aimed at "closingthe gap" in health and healthcare that have continued underthe Bush administration."

In contrast to the Europeanapproach to health inequities, itis racial and ethnic disparitiesthat are of greater policy rele-vance in the United States. Eirst,there are obvious historical rea-sons for the extensive overlap ofsocioeconomic and racial in-equalities in the United States.Second, the predominant use ofethnic and racial group cate-gories in most vital statistics,census, economic, and otherpopulation and health relateddata greatly facilitates monitor-ing disparities by race instead ofby social class.'" In fact, it hasbeen well demonstrated in theUnited States that socioeco-nomic differences between racesaccount for much of the racialdifferences in health, eventhough race per seor rather,the results of societal discrimina-tion based on racemay havean independent effect on health

status and health care access/utilization."""'

STRATEGIES IN THEDEVELOPING WORLD

The emergence of health eq-uity as a public health issue isalso occurring in the developingworld. Following the Alma-AtaPrimary Health Care Summit in1979, many national govern-ments in Latin America, Asia,and Afiica csime together to for-mulate a strategy for achievingthe goal of "Health for All."

The Alma-Ata summit advo-cated the achievement of greaterhealth equity and the reductionof health disparities as nationalgoals. Prior to the emergence ofthe HIV/AIDS epidemic in the1990s, many developing coun-tries achieved noteworthy im-provements in national averagelife expectancy and mortalityrates, even though health dispari-ties between socioeconomic andethnic groups within countriesactually increased in most cases.For example, in Latin Americaand the Caribbean, the regionthat experienced the highest rateof improvement in health indica-tors in that period, health dispari-ties were also the greatest. Theratio between the highest andlowest national infant mortalityrates in the region of the Ameri-cas was 7:1 in 1964 and hadrisen to 14:1 by 1994. Similarly,within Brazil, even though thenational infant mortality rate fellby 40% between 1977 and1995, the ratio between therural northeast and the rest ofthe country actually increasedfrom 1.7:1 to 2.0:1.^

In response to these dispari-ties, from 1996 to 2002 the PanAmerican Health Organizationundertook an ambitious effort topromote health equity in its tech-

2056 I Editorials American Journai of Public Heaith | December 2004, Vol 94, No. 12

nical cooperation programs inthe Americas by promoting re-search, benchmarking, strength-ening information dissemination,establishing databases, and im-proving health information analy-sis for monitoring and reducinghealth disparities within and be-tween countries in the region.^ ''^ ^In fact, some Latin Americancountriesfor example, CostaRica, Chile, Peru, Bolivia, andBrazilhave incorporated equitygoals into their national publichealth programs.

THE ROLE OF THEINTERNATIONALCOMMUNITY

The international communityalso has a role in the global cam-paign to confront health inequali-ties. Some international organiza-tions are already in the forefrontof this campaign. For example,the Poverty and Health Networkof the World Bank"'^" has devel-oped a methodology for the anal-ysis of socioeconomic differencesin health, nutrition, and popula-tion in developing countries thatis based on the World Bank'sdemographic and health surveys.This methodology provides amuch needed empirical approachfor monitoring intracountrytrends and intercountry compar-isons of health disparities.^ '^^ ^

In 1996, the Rockefeller Foun-dation and the Sweden Interna-tional Development CooperationAgency established a GlobalHealth Equity Initiative, with anetwork of more than 100 re-searchers in more than 15 coun-tries, for the purpose of raisingglobal awareness and buildingcapacity to address health in-equities. The most visible productof this effort was the publicationin 2001 of a groundbreaking

^^ that established a solid

conceptual and operationalframework, based on a globalperspective and country-specificanalysis, of health equity inwhich global and national deter-minants are closely interrelated(via the economic and social con-sequences of economic and fi-nancial globalization, political sta-bility and governance, povertyand development, ethnic con-flicts, migration, etc.). The reportemphasized the need tostrengthen the capacity of thehealth sector in all countries andprovide it with tools for tacklinghealth disparities, in partnershipwith all potential partners in gov-ernment and civil society.

Various current global initia-tives have emerged from theGlobal Health Fquity Initiativeand other aforementioned ef-forts. One is the Global EquityGauge Alliance, also supportedby the Rockefeller Foundationand the Sweden InternationalDevelopment CooperationAgency, which was created toparticipate in and support anactive approach to monitoringhealth inequalities and promot-ing equity within and betweensocieties. The Alliance cur-rently includes 11 member-teams, called Equity Gauges,located in 10 countries in theAmericas, Africa, and Asia.^*In sub-Saharan Africa, an ini-tiative closely linked to theGlobal Equity Gauge Allianceis EQUINET, the Regional Net-work on Equity in Health inSouthern Africa. EQUINET in-volves professionals, civil societymembers, policymakers, stateofficials, and academic, govern-ment, and civic institutions fromBotswana, Malawi, Mozambique,South Africa, Tanzania, Zambia,Zimbabwe, and the South Afri-can Development Communitywho have come together as an

equity catalyst to promote shai"edvalues of equity and social justicein health.^^

The International Society forHealth Equity, founded in 2000,has successfully held 3 interna-tional conferences with hundredsof participants from all conti-nents; today it constitutes themost authoritative internationalprofessional association of healthequity researchers, analysts,and advocates."'" The most re-cent conference, held in Durban,South Africa, in June 2004, dealtwith a myriad of emerging issuesfor effectively reducing healthdisparities in the developing anddeveloped world. Some of theseissues included insurance andfinance, resource allocation, ac-cess to care, special populationgroups, analytical methods fortime trends and life-course deter-minants, community action, so-cial empowerment, gender andhealth, law and human rights,local governance and planning,and the impact of HIV/AIDS.^'

The United Nations organiza-tions, such as the World HealthOrganization (WHO), also havea leadership role to play in theglobal effort to conlront healthinequalities. Such action is con-sistent with the 1998 WorldHealth Assembly resolution, whichconfirmed that a reduction in so-cioeconomic inequalities inhealth was a priority for all coun-tries.''^ In 2000, a special issueof the Bulletin of the World HealthOrganization "'' was devoted toinequalities in health, and theWHO Global Health Survey, ini-tiated in 2001, provides valuablehealth indicators that can becrossed with socioeconomic datato provide the basis for the moni-toring of health disparities.^ "*

Since 2003, under the leader-ship of Director General LeeJong-Wook, the issue of health

equity has acquired a new placein the priorities of WHO.^ ^ Anequity team has been establishedwithin the area of evidence andinformation for policy, with theobjective of supporting innova-tion and strengthening knowl-edge sharing on a global level.An expressed goal is to developnew forms of collaboration be-tween health experts and deci-sionmakers to translate currentevidence on the social and envi-ronmental determinants of healthdisparities into effective publicpolicy."" In his speech to the57th World Health Assembly inMay of this year, the WHO direc-tor general announced his inten-tion to set up and launch a newglobal commission formed by ex-pert public health scientists andpolicymakers to gather evidenceon the social and environmentalcauses of health inequities andways to overcome them, with thepurpose of providing guidancefor all WHO programs.^'

In summary, there is a globalmovement for health equity thatbegan in the last decade of the20th century and continues togrow. The role of informationand knowledge sharing is key inlinking this global effort to localactions and challenges; interna-tional and national health organi-zations in the developed and de-veloping countries, be they in thepublic sector or in civil society,must join hands with local com-munities and governments ifhealth inequities are to be effec-tively reduced.

The optimists among us be-lieve that the road toward global-ization can lead us to a future inwhich development becomesfreedom''^ and in which allhuman beings can enjoy com-plete citizenship, wherever theymay be; exercise the right togainful employment; and fully

December 2004, Vol 94, No. 12 | American Journal of Public Health Editorials I 2057

share in the benefits of knowl-edge and information.^^ Such aworld is one in which avoidableand unfair differences in the op-portunity to lead a healthy life-differences between men andwomen; among Black, White,and brown; among inhabitants ofthe North and South, East andWestwould cease to exist. Theroad to this world is a long one,one that will take us far beyondthe horizon. Although it beginson our very doorstep, it hasglobal dimensions, D

Juan Antonio Casas-Zamora,MD, MScSM

Said A. Ibrahim, MD. MPH

About the Authors]uan Antonio Casas-Zamora is with theLiaison Office to the European Union,World Health Organization, Brussels, Bel-gium. Said A. Ibrahim is with the Centerfor Health Equity Research and Promo-tion, VA Pittsburgh Healthcare System,Pittsburgh, Pa.

Requests for reprints should be sent toSaid A. Ibrahim, MD, MPH, Center forHealth Equity Research and Promotion,VA Pittsburgh Healthcare System, Univer-sity Drive C, Il-East (130A-U) Pittsburgh,PA 15240 (e-mail; said.ibrahim2@med.va.gov).

This editorial was accepted August 8,2004.

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