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This Article Extract Full Text (PDF) All Versions of this Article: AJPH.2005.080432v1 96/1/10    most recent Submit a response View Shopping Cart Alert me when this article is cited Alert me when eLetters are posted Alert me if a correction is posted Services Similar articles in this journal Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Victora, C. G. Search for Related Content PubMed Articles by Victora, C. G. Related Collections Health Policy Other Race/Ethnicity Socioeconomic Factors

Cesar G. Victora, MD, PhD

Postgraduate Program in Epidemiology, Universidade Federal de Pelotas, Pelotas, Rio Grande do Sul, Brazil

This issue of the Journal is dedicated to the theme of global engagement to eliminate health disparities. As stated in the classic "Black Report" on health inequalities in the United Kingdom, "an association between socioeconomic deprivation and ill-health has been found wherever and whenever it has been looked for" (Black D, Morris JN, Smith C, Townsend P. Report of the Working Group on Inequalities in Health [1980]. Reprinted in: Townsend P, Davidson N, Whitehead M, eds. Inequalities in Health: The Black Report and the Health Divide. London, England: Penguin Books; 1990). Today, the international statistics are staggering: in 2000, a child from sub-Saharan Africa was 29 times as likely as a child born in a high-income country to die by the age of 5 years.

In this issue, Chopra and Sanders review inequities in child health in South Africa, one of the world’s most unequal countries, in "Key Challenges in Attaining Health in an Inequitable Society: The Case of South Africa." They challenge the notion that a middle-income, inequitable country can undergo the epidemiological transition from an infectious to a chronic disease profile in a smooth fashion, arguing that whereas "the more affluent sections of the population have completed the epidemiological transition . . . economically disadvantaged groups continue to suffer from pretransitional pathologies."

Chopra and Sanders do not stop at denouncing inequities but move on to address the challenges faced by a government that, since 1994, has placed equity at center stage. They argue that political will is not enough—in the real world, there are a number of major barriers to reducing health inequities. These include inability to increase overall health spending, major outmigration of health personnel to rich countries, growing privatization of essential services, and limited absorptive capacity (i.e., limited ability to spend new funds, e.g., for antiretroviral treatment) in the poorer districts of the country.

The authors describe the Cape Town Equity Gauge project, one of 11 such projects in Africa, Asia, and Latin America. By monitoring inequities in health and health care, the project promotes community mobilization and generates advocacy for policy change. Once again confirming Tudor Hart’s "inverse care law" ( Hart J T. The inverse care law. Lancet. 1971;1[7696]:405–412[CrossRef][Web of Science][Medline]), the project has found that districts with the highest burden of disease are receiving far fewer health care resources than better-off districts. Although they accept these findings, managers and policymakers have found it extremely difficult to shift resources away from the wealthier districts. Chopra and Sanders conclude that "it seems clear that without sustained advocacy and organized community demand, significant change in resource allocation is unlikely to be effected."

A sharp counterpoint to the South African experience is described by Cooper and colleagues in "Cardiovascular Disease and Associated Risk Factors in Cuba: Prospects for Prevention and Control." Cuba’s population, like that of South Africa, consists of descendents of Europeans and Africans. Unlike South Africans, Cubans as a whole have completed the epidemiological transition. Their infant mortality rate is almost one tenth that of South Africa, and the country is now facing the challenge of reducing chronic disease mortality. There is a definite lesson to be learned for the international public health community from Cuba’s longstanding commitment to equity in health.

This Article Extract Full Text (PDF) All Versions of this Article: AJPH.2005.080432v1 96/1/10    most recent Submit a response View Shopping Cart Alert me when this article is cited Alert me when eLetters are posted Alert me if a correction is posted Services Similar articles in this journal Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Victora, C. G. Search for Related Content PubMed Articles by Victora, C. G. Related Collections Health Policy Other Race/Ethnicity Socioeconomic Factors