In pursuit of equity
====================

* Fiona Kouyoumdjian, MD MPH

**Health Inequality: Morality and Measurement** Yukiko Asada; University of Toronto Press; 2007; 294 pp $55.00

Many of us working in health care are concerned about health equity. However, we often lack a clear understanding of what equity means and how it should be measured, which makes it impossible to judge whether our work serves to reduce or to increase inequity. *Health Inequality: Morality and Measurement* will illuminate readers on these concepts.

This book's ambitious aim is to “build a theoretical and analytical framework for measuring health inequality.” The author, Dr. Yukiko Asada, defines health inequity as “the moral or ethical dimension of health inequality,” that is, those health inequalities that not only exist, but “are of moral concern due to the value we place on health.” She provides justification for why the distribution of health across a population may be seen as a moral issue: that health is a special good, as an important component of well-being, which is necessary and useful for a good life; that health equity plays an important role in the general pursuit of justice and equality, though may not have a special status; and that health inequality is an indicator of general social justice.

The book begins with an exploration of which health distributions are equitable, considering, for example, inequality that results from causes that are the responsibility of society as opposed to inequality that may result from individual choice. Asada then discusses which measurement strategies would be most appropriate to operationalize various concepts of equity and the complex process of summarizing a health distribution into one number. Finally, she conducts an empirical analysis of health inequity, leading readers step-by-step through an analysis of whether health equity changed in the United States from 1990 to 1995.

Throughout the book, Asada tackles fundamental questions about equity, such as whether we should consider determinants of health or functionality when we define health equity, whether we should compare equity across individuals or across groups of people within a society (such as racial or socio-economic groups), and whether we should measure the average health of a population or the proportion of people who meet a minimum standard of health. The discussion of these complex subjects is insightful and clear.

A challenge of this book, which may also be a strength, is that it bridges philosophy and quantitative methodology. So while *Health Inequality: Morality and Measurement* offers sound thinking and innovative approaches, the book demands a careful and dedicated reader to follow fairly sophisticated concepts and math. For such readers, the rewards are great.

## Footnotes

*   Dr. Kouyoumdjian, who is interested in equity issues in determinants of health, health care access and health outcomes, is currently completing a residency in community medicine and a doctorate in epidemiology.