Hi Gavin:

Here's some thinking about your interesting queries----see below in CAPS
under each of your questions.

Barbara Starfield




At 04:42 PM 10/13/2002 +0800, you wrote:
>Dear Barbara,
>
>I hesitate to weigh in but...
>
>1. Why would we think that there is, could be or should be some single
>uniquely correct definition of equity. Whatever equity is, it is likely to
>vary across cultures and societies.

THE ISEQH ( see the website at www.iseqh.org) PROVIDES A DEINIFITION OF
EQUITY IN HEALTH, NOT OF JUST 'EQUITY'
THE DEFINITION IS INTENDED TO BE GENERIC----TO APPLY IN GENERAL.  IF THERE
IS SOME REASON TO DEFINE EQUITY IN HEALTH DIFFERENTLY ACROSS CULTURES AND
SOCIETIES, THIS WOULD BE AN INTERESTING TOPIC TO DEBATE.

>2. Whatever it is, why would equity necesarily be defined solely in terms of
>health? What about access?
THE ISEQH HAS A SEPARATE DEFINITION FOR EQUITY IN RECEIPT OF HEALTH
SERVICES.  (see the website)

>3. It is implied in the definition that health is a construct that is common
>across all cultures and societies.
INTERESTING AND PROBABLY TRUE. BUT FOR A STARTER, TRY THE DEFINITION I
PROVIDED IN J EPID COMM HEALTH 2001; 55:452-4
AS WITH THE UNIVERSALITY (OR LACK OF IT) OF THIS DEFINITION---AS WITH THE
DEFINITION OF EQUITY IN HEALTH--THIS IS AN INTERESTING TOPIC FOR DEBATE.

>4. Why do inequities have to be 'systematic'? Cannot for example an
>individual general practitioner practice inequitably with respect to how she
>treats her patients?
I AM NOT SURE WHAT YOU MEAN HERE.  "INEQUITABLE" PRACTICE WOULD EXIST IF
THE PRACTITIONER WITTINGLY OR UNWITTINGLY SINGLED OUR ONE OR MORE
PARTICULAR POPULATION GROUPS FOR DIFFERENT TREATMENT NOT BASED ON THEIR
DIFFERENT NEEDS.   IF THE PRACTITIONER WAS RANDOM IN HIS OR HER UNWARRANTED
DIFFERENCES IN TREATMENT, THAT WOULD BE UNEQUAL (NOT INEQUITABLE) TREATMENT.

>5. Why do inequities have to be 'potentially remediable'? Why can't they
>just exist even if they cannot be remedied in reality or potentially?
WE NEED TO DISTINGUISH 'UNEQUAL' FROM 'INEQUITABLE'. DIFFERENCES IN
BIRTHWEIGHT BETWEEN  MALES AND FEMALES IS AN INEQUALITY, NOT AN INEQUITY.
NOTHING CAN BE DONE ABOUT IT (AT LEAST IN SO FAR AS WE KNOW).

>This Declaration has a slight smell of WHO-World-Health-Report-2000 elitism
>and universality.
I AM NOT SURE WHY YOU SAY THIS. THE MEMBERSHIP OF THE ISEQH INCLUDES PEOPLE
FROM ALL KINDS OF COUNTRIES.  I HAVE NOT HEARD ANY CRIES OF 'ELITISM' FROM
ANYWHERE;  ANOTHER INTERESTING TOPIC FOR DEBATE.

>There are some other strange ideas around the edges of this, such as that
>equity should be lexicographically ordered, seemingly always and everywhere,
>above efficiency. I will however restict my comments to the core.
I DON'T RECALL IF YOU ARE AN ECONOMIST OR NOT, BUT THIS COMMENT HAS BEEN
HEARD FROM OTHER ECONOMISTS. I SUPPOSE IT IS A VALUE JUDGMENT AS TO WHETHER
EFFICIENCY OR EQUITY SHOULD RECEIVE PRIORITY.  IT PROBABLY DEPENDS ON THE
SPECIFIC ISSUE AND SHOULD NOT BE GENERALIZED BUT, RATHER, LEFT FOR OPEN
DEBATE ON EACH ISSUE.

>Pursuing equity to me involves inter alia listening to the voices of those
>who are currently suffering as a result of inequities (whatever they are).
>Trying to decide for others, especially for the disadvantaged, which equity
>definition they should adopt seems at best inappropriate and, by reducing
>their autonomy still further, may actually create greater or new inequities.
>I thus tend to the view that the Declaration venture is flawed, whatever
>definition of equity were to be endorsed if that purports to be a universal
>definition.
I DID NOT DEVELOP THE DECLARATION----A COMMITTEE OF THE ISEQH DID, AND IT
WAS SUBJECTED TO DISCUSSION BY THE BOARD AND NOW BY THE MEMBERSHIP (AND
EVEN MORE WIDELY THROUGH A FEW LIST-SERVES). I WOULD POINT OUT, HOWEVER,
THAT "LISTENING TO THE VOICES OF THOSE WHO ARE CURRENTLY SUFFERING AS A
RESULT OF INEQUITIES REQUIRES HAVING SOME NOTION OF WHAT AN INEQUITY---OR
WHAT 'DISADVANTAGE-- IS!


>If some population group (say Aboriginal people) choose, on an informed and
>rational basis, to use some health care resources to promote their health
>(as they define it) which results in an increase in the gap between their
>health and that of some dominant population, health now defined according to
>the dominant culture's values (say western values), has inequity increased?
>Or again, if the gap in health (as defined by western values) were to be
>narrowed as a result of the dominant culture deciding how to allocate these
>resources (but ignoring the preferences of the dominated culture), what
>then?
IN A PARTICIPATORY (NOT PATERNALISTIC) SOCIETY, ALL POPULATION GROUPS WOULD
HAVE A SAY IN WHAT IS CONSIDERED POOR AND GOOD HEALTH.

>I think the Toronto Declaration is at best unhelpful...except, and this in
>my view is important, that it has stimulated some fascinating thoughts from
>a number of interested and interesting parties.
THANKS FOR THAT POSITIVE THOUGHT!  I AM SURE WE WILL ALL BENEFIT FROM THE
INCREASED ATTENTION TO HOW WE CAN MOvE TOWARADS EQUITY IN HEALTH.  THAT IS
WHAT THE ISEQH IS FOR, AND I FOR ONE AM GLAD THAT WE SEEM TO  BE ON OUR WAY.


>Is it still possible for the Toronto Declaration to be Undeclared?
WE WILL SEE WHAT THE EXECUTIVE BOARD SAYS!

>Warm regards
>
>Gavin
>

Barbara Starfield MD MPH
University Distinguished Professor
624 North Broadway-Room 452
Baltimore MD 21205
USA
Phone 410 955 3737
Fax 410 614 9046
email: [log in to unmask]