Life expectancy and reduction in mortality have declined significantly, particularly since 1980 in the United States, compared with other industrialized countries.1 At the same time, inequity in the distribution of disease, illness, and death have increased dramatically.2 For example, infant mortality is more than twice as high among Blacks than among Whites, even when controlling for socioeconomic factors. Diabetes prevalence is 291 percent higher in American Indians than in White Americans, and people of low income have almost eight times the rate of cardiovascular disease.3 Yet, the United States spends more on healthcare, both on per capita basis and as a proportion of its gross domestic product, than any other nation. These differences help explain why, of all industrialized nations, the United States ranks 37th in healthcare quality and 30th in the population's health status. These disparate outcomes parallel growing social and economic inequalities.4 In the United States, inequality is greater than in any other industrialized country in the world, with a high degree of residential segregation.5-7 Research has shown that material conditions and social circumstances are intimately tied to health status in a graded, enduring relationship.8 Therefore, the primary source of such health outcomes is predominantly associated with issues of class, racism, and gender discrimination that lead to a cascade of disadvantage, often independent of behavior or genetic differences.9 As Graham suggests, "Improving the overall health of the population does not eliminate the health disadvantages of disadvantaged groups."2^(pXiii)

Since the time of German physician Rudolph Virchow in 1848, who demonstrated that the etiology of disease is directly linked to social conditions, public healthcare practitioners have argued for social reforms.10 The great advances in life expectancy in the early 20th century in the United States were largely due to the sanitation movement, the abolition of child labor, and the introduction of the 8-hour workday rather than programs, services, or advances in medicine.11,12 Chernomas noted that the environment plays a more important role in determining disease than germs and genes themselves.13 In an effort to address health equity, the Ottawa Charter for Health Promotion in 1986 emphasized peace, shelter, income, education, and a stable ecosystem as critical prerequisites for health, and in 2005, the World Health Organization formed the Commission on the Social Determinants of Health. Healthy People 201014 sets health equity as a priority in the United States, and the 2003 Institute of Medicine report, Unequal Treatment: Confronting Racial and Ethnic Disparities in Healthcare,15 stresses its importance.

Challenges

With the exception of advances in social epidemiology-the branch of epidemiology that considers how social interactions and collective human activities affect health16^(p3)-public health today remains largely focused on changing behavior, lifestyles, and single risk factors, avoiding the underlying causes of health inequity. Factors such as limited-scope mandates, funding silos, fragmentation of institutional research, including a disconnect between academic research and public health practice, and isolation from other disciplines and systems perpetuate the development and implementation of interventions targeted toward behavioral change rather than the conditions within and under which people live. In addition, local and state health agencies as well as institutions that serve as first responders, are experiencing increasing pressures as their boundaries and scope expand to act on new challenges such as climate change and related natural disasters, new and evolving diseases, and man-made disasters. The type of infrastructure, workforce, and community capacity-building and tracking systems among other elements required to tackle health inequities often remain unexamined and underdeveloped. Public health resources are primarily targeted toward crisis management and few resources are directed toward action on the social determinants of inequities. The dominant paradigm underlying disease prevention and health protection in public health often does not consider factors such as differential political and economic power among groups and the way changes in economic conditions, agricultural practices, and ecological transformation matter to public health.17 Such efforts have been sporadic and uncoordinated.

Opportunities

In the last few years, mounting interest in health equity and social justice portends momentum that should encourage new initiatives and organizing for change. For example, health equity is a major goal of Healthy People 2010 and the Institute of Medicine. In addition, the Centers for Disease Control and Prevention has formed a National Expert Panel on Social Determinants of Health to provide the agency with recommendations on its role in addressing health equity. Also, at the federal level, funding from the Department of Health and Human Services, Office of Minority Health for the states and the existence of organizations such as the National Association of State Offices of Minority Health that support states offer promise of the establishment of a true community of practice to address racial and ethnic health inequities. At least six state health departments-California, Massachusetts, Oklahoma, Oregon, Virginia, and Washington-have begun organizational efforts to develop comprehensive strategies and policy related to health equity. At the local level, among multiple examples, the Connecticut Association of Directors of Health has developed a Health Equity Index as a tool to provide a portrait of conditions in a community.

Momentum has also built beyond the public health agencies. For example, the Robert Wood Johnson Foundation has formed a new commission, the Commission to Build a Healthier America, which emphasizes social determinants of health. In 2008, a group of healthcare practitioners formed the Academy for Health Equity designed to create a social movement that will ensure equal opportunity for health. In academia, extensive research continues to document the strong relationship between social and economic inequalities and health inequality. Finally, new attention to the issue has been driven by the release of the PBS documentary series Unnatural Causes: Is Inequality Making Us Sick? Approximately 115 local health departments have signed on to conduct town hall events to screen the series and engage in dialogue with communities.

Looking Forward

The United States will not achieve health equity and end disparities through traditional public health practice alone or by endlessly treating the consequences of health inequity without systematically tackling the root causes. These causes, embedded in social policy and institutional practices, structure the possibilities for health or illness. Health equity will require long-term strategies with many institutions that influence health outcomes such as housing, transportation, and planning. Equally critical is a redefinition of working with communities, respecting their knowledge, insights, and firsthand experience. Health officials can play a leadership role by using their credibility and position to raise public awareness of health inequity, advocate for effective public policy, and engage with and mobilize their communities. Innovation is essential, supported by robust evaluation, to determine an evidence base for continued improvement. Academic study to capture the critical elements of innovative policy and program interventions will permit the spread of innovation to new communities and in new settings. The approach must be comprehensive, rather than improvisational, emphasizing the reduction of social and economic inequalities. Officials can also devise a framework and a common language that clearly expresses the social injustices at the heart of health inequities. More specifically, the evidence base needs to incorporate knowledge beyond what is available in clinical epidemiology. That is, information about economic trends, investments in neighborhoods and community infrastructure, as well as the condition of housing and school facilities, will be critical in explaining likely health outcomes. Involvement in social reform was a part of public health at its inception and accounted for the great advances in life expectancy in the early part of the 20th century. Achieving health equity will demand a similar commitment.

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