Desigualdades en salud: nuevas perspectivas teóricas

Naomar Almeida-Filho

doi:10.18294/sc.2020.2751

Health inequalities: new theoretical perspectives

Naomar Almeida-Filho PhD en Epidemiología. Investigador I-A del Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq). Profesor Titular jubilado, Instituto de Saúde Coletiva, Universidade Federal da Bahia. Profesor Visitante, Instituto de Estudios Avançados Universidade de São Paulo, Brasil.

Received: 2 March 2020, Accepted: 13 June 2020, Published: 20 June 2020

https://doi.org/10.18294/sc.2020.2751 | PMID: 32574463

Abstract views

6169

Metrics Loading ...

PDF (Español)

Abstract

This article, I intend to articulate the theoretical problem of economic and social inequalities with the issue of the social determination of health. Initially, I provide a summary of Rawls’ and Sen’s theories of justice and equity as an illustration of the dominant perspective in Northern epistemologies. Second, I discuss applications of this theoretical framework in the literature on social inequalities and the social determination of health-illness-care. Thirdly, I present a semantic matrix proposed for the difference-distinction-inequality-inequity-iniquity series to help reduce the existing terminological confusion. Next, I introduce a synthetic theoretical model about the poverty-inequality dyad, referring to the concepts of social resources, health practices, health services, and health situation/conditions. Finally, oriented by an epistemological perspective from the global South, and taking the current Brazilian situation as a case study, I discuss political implications of the complex contemporary conjuncture, pertinent to the hypothesis that a process of transformation of economic inequalities into new forms of social inequities and health iniquities is currently underway.

Keywords: Socioeconomic Factors, Social Determinants of Health, Health Equity

References

1. Almeida-Filho N. Desigualdades de salud en función de las condiciones de vida: análisis de la producción científica en América Latina y el Caribe y bibliografía anotada. Washington DC: OPS; 1999.

2. Organización Panamericana de la Salud. Macrodeterminantes de la Inequidad en Salud [Internet]. Washington DC: OPS; 2000 [citado 2 nov 2019]. Disponible en: https://tinyurl.com/yaxcdjdt

3. Almeida-Filho N, Kawachi I, Filho AP, Dachs JN. Research on health inequalities in Latin America and the Caribbean: bibliometric analysis (1971-2000) and descriptive content analysis (1971-1995). American Journal of Public Health. 2003;93(12):2037-2043.

4. Breilh J. La determinación social de la salud como herramienta hacia una nueva salud pública (salud colectiva). Revista Faculdad Nacional de Salud Pública. 2013;31(Supl 1):S13-S27.

5. Wagstaff A, van Doorslaer E. Income inequality and health: what does the literature tells us?. Annual Review of Public Health. 2000;21:543-567.

6. Wilkinson RG. Unhealthy societies: the afflictions of inequality. London: Routledge; 1996.

7. Wilkinson R, Marmot M, (eds.). Social determinants of health: The solid facts. Copenhagen: World Health Organization; 2003.

8. Berkman L, Kawachi I. Social epidemiology. New York: Oxford University Press; 2000.

9. Thoits P. Stress and health: major findings and policy implications. Journal of Health and Social Behavior. 2010;51(Suppl):S41-S53.

10. Marmot M. The status syndrome: How social standing affects our health and longevity. New York: Owl Books; 2005.

11. Coburn D. Income inequality, social cohesion and the health status of populations: the role of neo-liberalism. Social Science & Medicine. 2000;51(1):135-146.

12. Diederichsen F, Evans T, Whitehead M. Chapter 2: the social basis of disparities. In: Evans T, Whitehead M, Diderichsen F, Bhuiya A, Wirth M, (eds.). Challenging inequities in health. London: Oxford University Press; 2001. p. 53-64.

13. Krieger N. Theories for social epidemiology in the 21st century: an ecosocial perspective. International Journal of Epidemiology. 2001;30(4):668-677.

14. Samaja J. Epistemología y metodología: Elementos para una teoría de la investigación científica. Buenos Aires: EUDEBA; 2005.

15. Samaja J. Epistemología de la Salud. Buenos Aires: EUDEBA; 2005.

16. Habermas J. Direito e democracia: entre facticidade e validade. Rio de Janeiro: Tempo Brasileiro; 2003.

17. Rawls J. A theory of justice. Cambridge: Harvard University Press; 1971.

18. Rawls J. Justice as fairness: a restatement. Cambridge: Harvard University Press; 2001.

19. Rawls J. Political Liberalism. New York: Columbia University Press; 2005.

20. Mill JS. Utilitarianism. Cambridge: Hackett Publishing Company; 2001.

21. Hart HLA. Rawls on liberty and its priority. In: Daniels N, (ed.). Reading Rawls. Stanford: Stanford University Press; 1989.

22. Sen A. On economic inequality. New York: Oxford University Press; 1981.

23. Sen A. Inequality reexamined. New York: Oxford University Press; 1992.

24. Foster J, Sen A. On economic inequality after a quarter century. In: Sen A. On economic inequality (Expanded Edition). New York: Oxford University Press; 1997. p. 121-220.

25. Sen A. ¿Por qué la equidad en salud?. Revista Panamericana de Salud Pública. 2002;11(5/6):302-309.

26. Marx K. Crítica ao programa de Gotha. In: Marx K, Engels F. Textos. São Paulo: Alfa-Omega; 1977.

27. Marx K. O capital: crítica da economia política. São Paulo: Abril Cultural; 1984.

28. Bourdieu P. La distinción: Criterios y bases sociales del gusto. Madrid: Taurus; 1988.

29. Piketty T. Capital et idéologie. Paris: Editions du Seuil; 2019.

30. Sousa-Santos B. Introducción a las epistemologías del sur. En: Meneses MP, Bidaseca K, (coords.). Epistemologías del sur. Buenos Aires: CLACSO-Coimbra; 2018. p. 25-64.

31. Sousa-Santos B. O fim do império cognitivo: a afirmação das epistemologias do sul. Belo Horizonte: Autêntica; 2019.

32. Almeida Filho N. Towards a unified theory of health-disease: II - Holopathogenesis. Revista de Saúde Pública. 2014;48(2):192-205.

33. Whitehead M. The concepts and principles of equity and health. International Journal of Health Services. 1992;22(3):429-445.

34. Whitehead M. A typology of actions to tackle social inequalities in health. Journal of Epidemiology and Community Health. 2007;61(6):473-478.

35. Ossanai J. Reformas contemporáneas en el campo de la salud: en busca de la equidad. Rockville: Technical Resources International Inc. ; 1994.

36. Metzger X. Conceptualización e indicadores para el término equidad y su aplicación en el campo de la salud. Washington: OPS; 1996.

37. Bambas A, Casas JA. Assessing equity in health: conceptual criteria. En: Equity and health: Views from the Pan American Sanitary Bureau. Washington DC: Pan-American-Health-Organization; 2001. Ocassional Publication No 8, p. 12-21.

38. Daniels N, Kennedy B, Kawachi I. Is inequality bad for our health?. Boston: Beacon Press; 2000.

39. Peter F, Evans T. Ethical dimensions of health equity. En: Evans T, Whitehead M, Diderichsen F, Bhuiya A, Wirth M (ed.). Challenging inequities in health: from ethics to action. London: Oxford University Press; 2001. p. 25-33.

40. Spinelli H. Condiciones de Salud y Desigualdades Sociales: historias de iguales, desiguales y distintos. En: Críticas e atuantes: Ciências Sociais e Humanas em Saúde na América Latina. Minayo MC, Coimbra C, (org.). Rio de Janeiro: Editora Fiocruz; 2005. p. 315-332.

41. Macinko JA, Starfield B. Annotated Bibliography on Equity in Health, 1980-2001. International Journal for Equity in Health. 2002;1(1):1-20.

42. Macinko JA, Shi L, Starfield B, Wulu Jr JT. Income inequality and health: a critical review of the literature. Medical Care Research and Review. 2003;60(4):407-452.

43. International Society of Equity in Health (ISEqH) [Internet]. Home [citado 10 jun 2019]. Disponible en: http://www.iseqh.org

44. Vieira da Silva LM, Almeida-Filho N. Equidade em saúde: uma análise crítica de conceitos. Cadernos de Saúde Pública. 2009;25(Supl 2):S217-S226.

45. Wagstaff A, Van Doorslaer E. Measuring inequalities in health in the presence of multiple-category morbidity indicators. Health Economics. 1994;3(4):281-289.

46. Alazraqui M, Mota E, Spinelli H. El abordaje epidemiológico de las desigualdades en salud a nivel local. Cadernos de Saúde Pública. 2007;23(2):321-330.

47. Bommier A, Stecklov G. Defining health inequality: why Rawls succeeds where social welfare theory fails. Journal of Health Economics. 2002;21(3):497-513.

48. Kawachi I, Subramanian S, Almeida-Filho N. A glossary for health inequalities. Journal of Epidemiology and Community Health. 2002;56(9):647-652.

49. Braveman P. Health disparities and health equity: Concepts and measurement. Annual Review of Public Health. 2006;27:167-194.

50. Braveman P. What are health disparities and health equity? We need to be clear. Public Health Reports. 2014;129(Supl 2):S5-S8.

51. Arcaya MC, Arcaya AL, Subramanian SV. Desigualdades en salud: definiciones, conceptos y teorías. Pan American Journal of Public Health. 2015;38(4):261-271.

52. Almeida-Filho N. Modelos de determinação social das doenças crônicas não-transmissíveis. Ciência & Saúde Coletiva. 2004;9(4):865-884.

53. Almeida-Filho N. A problemática teórica da determinação social da saúde (nota breve sobre desigualdades em saúde como objeto de conhecimento). Saúde em Debate. 2009;33(83):349-370.

54. Wainwright SP, Forbes A. Philosophical problems with social research on health inequalities. Health Care Analysis. 2000;8(3):259-277.

55. Breilh J. El género entre fuegos: inequidad y esperanza. Quito: Centro de Estudios y Asesoría en Salud; 1996.

56. Breilh J. Epidemiologia Crítica: Ciência Emancipadora e Interculturalidad. Buenos Aires: Lugar Editorial; 2003.

57. Breilh J. La determinación social de la salud como herramienta de transformación hacia una nueva salud pública (salud colectiva). Revista Facultad Nacional de Salud Pública. 2013;31(Supl 1):S13-S27.

58. Breilh J. Epidemiología del siglo XXI y ciberespacio: repensar la teoría del poder y la determinación social de la salud. Revista Brasileira de Epidemiologia. 2015;18(4):965-9745.

59. Gatrell AC, Popay J, Thomas C. Mapping the determinants of health inequalities in social space: Can Bourdieu help us?. Health Place. 2004;10(3):245-257.

60. Heller A. Além da justiça. Rio de Janeiro: Civilização Brasileira; 1998.

61. Sousa-Santos B. Para uma revolução democrática da justiça. São Paulo: Cortez; 2017.

62. Asada Y. A framework for measuring health inequity. Journal of Epidemiology and Community Health. 2005;59(8):700-705.

63. Ayres JRCM. Acerca del riesgo: Para comprender la epidemiología. Buenos Aires: Lugar Editorial; 1997.

64. Ayres JRCM, Calazans GJ, Saletti Filho HC, Franca Junior I. Risco, vulnerabilidade e práticas de prevenção e promoção da saúde (2009). En: Tratado de saúde coletiva. São Paulo: HUCITEC-FIOCRUZ; 2009.

65. Testa M. Saber en salud: la construcción del conocimiento. Buenos Aires: Lugar Editorial; 1997.

66. Marmot M. Social determinants of health inequalities. Lancet. 2005;365(9464):1099-1104.

67. World Health Organization, Commission on Social Determinants of Health. Closing the gap in a generation: Health equity through the social determinants of health[Internet]. Geneva: World Health Organization; 2008[citado 10 jun 2019]. Disponible en: https://tinyurl.com/ycg9k8vx

68. Raphael D. Tackling Health Inequalities: Lessons from International Experiences. Toronto: Canadian Scholars’ Press; 2012.

69. Krieger N, Alegría M, Almeida-Filho N, Da Silva JB, Barreto ML, Beckfield J, Berkman L, Birn AE, Duncan BB, Franco S, et al. Who, and what, causes health inequities? Reflections on emerging debates from an exploratory Latin American/North American workshop. Journal of Epidemiology & Community Health. 2010;64(9):747-749.

70. Braveman P, Egerter S, Williams D. The social determinants of health: coming of age. The Annual Review of Public Health. 2011;32:381-98.

71. Braveman P, Gottlieb L. The social determinants of health: it’s time to consider the causes of the causes. Public Health Reports. 2014;129(S2):19-31.

72. Rocha PR, David HM. Determinação ou Determinantes? Uma discussão com base na Teoria da Produção Social da Saúde. Revista da Escola de Enfermagem da USP. 2015;49(1):129-135.

73. Borde E, Hernández M. Revisiting the social determinants of health agenda from the global South. Global Public Health. 2019;14(6-7):847-862.

74. Franko W, Tolbert C, Witko C. Inequality, self-interest, and public support for “Robin Hood” tax policies. Political Research Quarterly. 2013;66(4):923-937.

75. Waitzkin H, Iriart C, Estrada A, Lamadrid S. Social medicine then and now: Lessons from Latin America. American Journal of Public Health. 2001;91(10):1592-1601.

76. Pearce N. Epidemiology in Latin America: An opportunity for a global dialogue. Journal of Epidemiology & Community Health. 2008;62(9):762-763.

77. Laurell AC. La salud-enfermedad como proceso social. Revista Latinoamericana de Salud. 1982;2(1):7-25.

78. Laurell AC. Social analysis of collective health in Latin America. Social Science & Medicine. 1989;28(11):1183-1191.

79. Gonçalves R, Ayres JR, (org.), Santos L (org.). Saúde, Sociedade e História: Uma revisita às contribuições de Ricardo Bruno Mendes-Gonçalves. São Paulo: Hucitec; 2017.

80. Castellanos PL. Epidemiologia, saúde pública, situação de saúde e condições de vida. Considerações conceituais. En: Barata RB Condições de vida e situações de saúde. Rio de Janeiro: ABRASCO; 1997. p. 31-75.

81. Castellanos PL Perfis de mortalidade, nível de desenvolvimento e iniquidades sociais na região da Américas. En: Barata RB, Barreto ML, Almeida Filho N, Veras RP (orgs.). Equidade e saúde: contribuições da epidemiologia. Rio de Janeiro: FIOCRUZ, ABRASCO; 1997. p. 137-162.

82. UN Millennium Project. Investing in development: a practical plan to achieve the Millennium Development Goals [Internet]. New York: United Nations; 2005 [citado 10 jun 2019]. Disponible en: https://tinyurl.com/ybs9jvty

83. Murray CL, Lopez A. The Global Burden of Disease. Cambridge: Harvard University Press; 1996.

84. Vasconcellos M. Serviços de Saúde: uma revisão de processos de regionalização, análises de padrões espaciais e modelos de localização. En: Najar AL, Marques E (orgs.). Saúde e espaço: estudos metodológicos e técnicas de análise. Rio de Janeiro: Editora FIOCRUZ; 1988. p. 63-93.

85. Nery M. A dívida social. Conjuntura Econômica. 2002;56(2):38-39.

86. Paim J, Travassos C, Almeida C, Bahia L, Macinko J. The Brazilian health system: history, advances, and challenges. The Lancet. 2011;377(9779):1778-1797.

87. Nunes A, Santos JRS, Barata RB, Vianna SM. Medindo as desigualdades em saúde no Brasil: uma proposta de monitoramento. Brasil: OPS/IPEA; 2001.

88. Victora CG, Aquino EM, do Carmo Leal M, Monteiro CA, Barros FC, Szwarcwald CL. Maternal and child health in Brazil: Progress and challenges. The Lancet. 2011;377(9780):1863-1876.

89. Macinko J, Lima-Costa MF. Erratum: Horizontal equity in health care utilization in Brazil, 1998-2008. International Journal for Equity in Health. 2012;11(1):33.

90. Rasella D, Basu S, Hone T, Paes-Sousa R, Ocké-Reis CO, Millett C. Child morbidity and mortality associated with alternative policy responses to the economic crisis in Brazil: A nationwide microsimulation study. PLoS Med. 2018;15(5):e1002570.

91. Almeida-Filho N. Social inequality and human development: Intertwined cycles of perversion in education in contemporary Brazil. Encounters in Theory and History of Education. 2015;16:84-100.

92. Almeida-Filho N. Higher education and health care in Brazil. The Lancet. 2011;377(9781):1898-1900.

93. Costa S. A Desigualdades, Interdependência e Políticas Sociais no Brasil. En: Pires RR, (orgs.). Implementando desigualdades: reprodução de desigualdades na implementação de políticas públicas[ Internet]. Rio de Janeiro: Instituto de Pesquisa Econômica Aplicada; 2019 [citado 10 jun 2019]. Disponible en: https://tinyurl.com/yc8ge2a2

94. Wagstaff A. Benefit-incidence analysis: Are government health expenditures more pro-rich than we think?. Health Economy. 2012;21(4):351-366.

95. Griffin S, Love-Koh J, Pennington B, Owen L. Evaluation of intervention impact on health inequality for resource allocation. Medical Decision Making. 2019;39(3):171.

96. Piketty T. El capital en el siglo XXI. Madrid: Fondo de Cultura Económica; 2015.

97. Schrecker T. Neoliberalism and Health: The linkages and the dangers. Sociology Compass. 2016;10(10):952-971.

98. Schrecker T. Globalization, austerity and health equity politics: Taming the inequality machine, and why it matters. Critical Public Health. 2016;26(1):4-13.

99. Pickett KE, Wilkinson RG. Income inequality and health: A causal review. Social Science & Medicine. 2015;128:316-326.

100. Lynch J. Regimes of inequality: The political economy of health and wealth. Cambridge: Cambridge University Press; 2020.

101. Beckfield J, Bambra C, Eikemo T, Huijts T, Mcnamara C, Wendt C. An institutional theory of welfare state effects on the distribution of population health. Social Theory & Health. 2015;13(3):227-244.

102. Sell SK, Williams OD. Health under capitalism: a global political economy of structural pathogenesis. Review of International Political Economy. 2020;27(1):1-25.