什么是卫生公平? 这个想法是如何产生的?为什么它很重要

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这个想法和现代医学一样古老，和最新的医学研究一样新颖. No matter how you look at health equity, the conversation involves contradictions.

但其核心是关于疾病和健康的基本问题, say experts who have watched the conversation move from the fringes of scholarly debate to the mainstream of 21st century health care.

术语可以是抽象的，但事实不是. The richest 1% of Americans have a life expectancy that's at least 10 years higher than those in the poorest 1%. 一个人住在哪里可以预测他患心脏病的可能性, 高血压, 糖尿病和其他疾病.

卫生公平旨在解决这一问题. “卫生公平意味着我们实现了尽可能平等的健康, 在我们能解决的问题范围内,”医生说。. 波士顿大学公共卫生学院院长Sandro 最低潮说.

Because explanations of health equity overlap with terms such as inequality and justice, 隐喻会派上用场.

最低潮, 谁已经研究健康公平问题25年了, 用这个:如果一个人比另一个人高, 这种不平等是无法解决的. 然而, 如果药品被放在只有高个子才能够到的高架子上, 解决方案涉及到公平.

他说:“卫生公平就是要解决可解决的卫生差距. “往往, 卫生不平等反映了一种不公正, 在这一点上，我们没有对可以解决的问题给予足够的重视."

用更具体的术语来说, 最低潮 said there could be many reasons why one person has higher cholesterol levels than another. 但是“如果你的胆固醇比我的低，因为你可以吃西兰花, 我能吃到的只有薯片, 问题变成了, “这是为什么??'"

在一个经常被争论和传播的插图中, equity is likened to people attempting to watch a baseball game over a fence; a short person will need a boost that a taller one doesn't.

但 such "catchy and compelling brief definitions leave a lot of blanks to be filled in,”医生说。. Paula Braveman, founding director of the Center for Health Equity at the University of California, 旧金山.

Braveman, 家庭社区医学名誉教授, 他说如果你问100位专家健康公平的定义, 你可能会得到100个完全不同的回复. And if you asked her for a definition at different times over the three decades she's been studying the topic, 你可能会得到不同的答案."

如今，她更喜欢的定义来自一个 罗伯特·伍德·约翰逊基金会报道 that she helped write: "Health equity means that everyone has a fair and just opportunity to be as healthy as possible. 这就需要消除贫困等健康障碍, 歧视, 以及它们的后果, 包括无能为力和无法获得待遇公平的好工作, 优质教育和住房, 安全的环境, 还有医疗保健."

这些因素被称为健康的社会决定因素, 这是另一个伴随着健康公平而成熟的学术术语.

这也是为什么关于卫生公平的讨论经常包含历史教训的原因. To cite just one example of how events from nearly a century ago can affect health today, 20世纪30年代, racist redlining by banks limited where Black Americans could live and whether they could get mortgages. 直到今天, the neighborhoods they were restricted to are disproportionately exposed to pollution, have less access to healthy food and have higher rates of major cardiovascular problems and heart failure.

加利亚对这些问题提供了另一个比喻. 他说，想象一只在碗里的金鱼. "Say it exercises, swims around its bowl, eats healthy food, has a good goldfish doctor. 但是除非你换水，否则它根本不健康."

1966年，“健康公平”一词首次出现在医学研究中, 和关于卫生公平的想法得到了Dr. 马丁·路德·金. 在那十年里.

但 最低潮 said concepts about social justice and health go back at least to the mid-19th century, 当时德国科学家鲁道夫·维尔绍, 微生物学的先驱, linked a typhus epidemic to social conditions and said the solution was not for more doctors or hospitals but for social changes such as higher wages and universal education.

That makes health equity an old idea, 最低潮 said, but it's seen a resurgence in the past 25年. "And I think the resurgence of interest has been influenced by a recognition that health should be distributed fairly and evenly."

布拉曼第一次听到这个词是在20世纪90年代初, 当时她正在为世界卫生组织工作. 在美国.S.她说，学术兴趣最初集中在医疗保健方面的种族差距. “有一场相当活跃的运动关注健康差距, 人群立刻举起了医疗公平的旗帜, 因为这对人们来说是积极的”, 她说.

统计数据显示，研究兴趣在20世纪90年代和21世纪初飙升. 布拉曼说，部分原因是“种子已经播下”,这个想法的时机已经成熟.

全球政治也起了作用. 在90年代初苏联解体之前, 他说:“谈论这些问题时，人们必须如履薄冰,布拉曼说. 直到全球共产主义的退却，美国的公共卫生专家才意识到这一点.S. 即使使用“社会正义”这个词也能感到安心.

“那时候你真的做不到，”她说. "You could try to talk around it or hint at it using some very concrete illustrations, 但你不能说“社会正义”.'"

在接下来的二十年里, Braveman写过, the importance of health equity and the social forces that shape health moved "from obscurity and stigma to daylight and respectability."

In 2020, the COVID-19 pandemic brought equity issues into the public consciousness. 冠状病毒的死亡率在种族和民族之间存在巨大差异, 这个国家面临着某人的工作, 家庭甚至互联网接入都可能是生死攸关的问题.

“我确实认为COVID具有催化作用，”加利亚说.

现在, 他说, "there's a generation of public health scientists and practitioners who see health equity as being at the very heart of what they do."

Braveman is cautiously hopeful that generation will be able to build on the momentum they've developed. 在未来几十年里, "I would hope that we would move probably slowly but steadily in the direction of greater health equity."

但, 她说, progress won't happen without widespread understanding that "there's no health equity without equity.公众必须愿意在“贫困”问题上采取行动, 照顾孩子, 住房歧视, 优质教育——所有这些健康的社会决定因素."

这使得医疗公平成为一个政治问题. Which, to her, means that the future of health equity will be determined at the voting booth.

最低潮同意卫生公平不能脱离政治. 但这并不意味着它必须是分裂的, 他说, “因为我认为没有良心的人, 无论党派如何, 实际上认为健康差距是一件好事, 或凭良心的."

He looks ahead with an optimism, informed by the past, that comes from embracing contradictions.

在过去的25年里, 他说, “我认为人们已经充分认识到健康不平等的重要性." And while discrepancies between Black and white Americans are "unacceptably wide,“已经取得了进展.

例如，在2000年至2019年期间， 死亡率 心血管疾病的发病率下降, 黑人和白人之间的差距也缩小了, according to a study published in the 美国心脏协会 journal Circulation in 2022. 联邦数据显示在1900年, 美国黑人和白人的预期寿命差距超过14岁. 到2021年，这一差距缩小到5.5年.

因此，“世界是一个可怕的地方”可能同时是对的, and the world needs to get much better – but the world is a much better place than it's ever been,加利亚说. “这三件事都是真的."