Welcome back. This is the last module of Week 5 where we're talking about measurement.

And in this module, we're going to talk about inequalities. In particular, how to measure inequalities. The first and perhaps most critical point is we need to distinguish. Whether we're measuring inequalities in health outcomes, these people have more cancer than those people, blood pressure here is higher than blood pressure there and so forth. Inequality in health outcomes or inequality in resources; such as income. These people have more money than those people. The rich people have 90% of all the money and the poor people have or the rest of the people have 10%. So it's important to keep straight in our heads the distinction between inequalities and health outcomes and inequalities in what might be drivers of those health outcomes. Such as income or wealth or something like that in the social system. want to focus now on measuring inequality in health outcomes that will be the focus we've talked in other places about different aspects of the social system creating inequalities for better or worse. But now, we're going to talk about how to measure inequalities and health outcomes. Why would we want to do this? Well, one reason is we want to be able to detect, find and evaluate health disparities. If we don't measure inequalities, we don't measure some sense of this group has more and this group has less. We can't identify where you might want to spend our collective resources, where you want to do some interventions to improve, say breast cancer screening in this group, because that group is already doing it quite well. We also want to measure inequalities to assess change over time, as the social systems change, politics change, economic systems change, what's happening to health over that same period. So we can measure the change in the economic system and see whether there's a different spread or a greater inequality in health outcomes over time... And relatedly, we want to measure

inequalities to evaluate policy changes. Is a new tax program going to make people, on average, more alike in terms of their health outcome or some will be much better off and others will be much worse off? So these are some of the reasons why we want to measure inequalities. It's important to keep in mind that it's an or equation with respect to measurement, so often I see the mistake of students and scholars conflating these two ideas. Now the idea of measurement can be quite the same, when we're measuring an equality... Well, conceptually, what we're measuring is different. One is health and one is income or a driver of health, and so, that's why I have the big or in this slide. When we talk about measuring inequality some of the key ideas behind this are, are we measuring absolute differences? There is a 5% difference for this group compared to that group. This group is 10, that group is 20, the difference is 10 or are we going to measure relative differences. This group is 10, that group is 20. The second group is twice as good or bad as the first group. So it's about subtraction or ratios or division, if you want. These are key ideas on measuring inequality. We have to keep clear whether we're talking about absolute differences, a subtraction typically, were the relative differences, and we're talking about ratios, one number over another number. Relatedly, when we talk about inequalities, we always need to ask compared to whom, is there a particular reference group, the group that's most healthy, least healthy, most advantaged, least advantaged. The average group, the worse off group, these are questions that we always have to keep in mind when we're thinking about measuring inequality. Compared to what, compared to whom? When we talk about actually measuring inequality and you'll see some of this in your reading, we can talk about individual, that is person-to-person differences. We can talk about the maximum range. So, the least healthy person might be least healthy on some a some,

self-reported scale, their say that, I have bad health on a score of one. And the most healthy person might say, I have good health, I have a score of nine. Well, the difference there of course can be calculated and we can talk about the maximum range, one to nine. We could also use some pretty simple math and calculate what's called a statistical variance or its causing the standard deviation, here as std dev, standard deviation. And you can look up how to do this and the question here is not the maximum range but, what sort of the average variability from the average. Some are more, some are less, on average, this amount of dispersion or variability is some number. When we also talk about inequalities, measuring them that is, we can talk about group differences. So, not only can we talk about there's a difference between one person versus another and calculate some variance over a bunch of people. We can say that this group, males for example, has this amount of blood pressure, that group females has that amount of blood pressure. And again, we could take the subtraction, the absolute difference, or the ratio of those and say the males have 1.5 or some number like that the level of blood pressure of females. Some might say that males have, in this made-up example, 50% greater blood pressure. So this is how the measure of inequality works. We can do it at the individual level, we can do it at the group level. There are many sophisticated that is beyond this measure. Many sophisticated measures of inequality and I do not have time or perhaps skill to go in to them all with you now. Let me just offer a couple. One of the big ones in epidemiology is called population attributable risk, sometimes population attributable fraction. And here, this PAR measure is a summary of social group risk compared to the best off group, so again, the reference point is the best off or the healthiest group. And the calculation, and there's some math behind it, it's not very difficult, is about how much would the other groups need to change to achieve the health of

that reference group, the best off group. And then, scholars can say, well, that's the population attributable risk, where people need to improve their health some percent in order to gain the health of the most advantaged. Now, this is a very useful interesting statistic or measure of inequality. Well, one of the things I want to caution you about is that it assumes that nothing else changes. So to be simple, if we go to the measuring wealth for example. If we took all the wealth from the rich and gave it to the poor, that would equate, folks, make them more equal, but that would assume that nothing happens thereafter. And we know in social systems, that's not the case. They're dynamic, and they re-seek a new equilibrium. So the key assumption in the population attributable risk and it's related measures is that nothing else happens. And so, that's a cautionary tale when you're reading or in fact calculating one of these more sophisticated measures of inequality. Another commonly used measure of inequality is called the Gini or Gini Coefficient, depending on who you ask. I'll say Gini. In here, it's the measure of association between each social group's share of the population, how much does the group make. Tall people are 30% of the total population or something like that ranked by their health and their share of the health. Now, this measure this Gini Coefficient ranges from zero, it can't go less than 0 all the way to 1.. And so the question is, how much inequality is there in a given society? And this is typically measured by this graph that's well-known and the main diagonal line is a line of equality. So this is a line. If you're on that, this says that the society is equal. And then that curved line below it is called the Lorenz curve. And that's some measure of inequality. And so as the Gini Coefficient goes from 0 to 1, that line changes, the lower line, the curved line, the Lorenz curve. And so this is one way to measure inequality of income often done in economics, or health, typically done in

social epidemiology. And you can read more about the Gini Coefficient, there's some very good websites that describe it in richer detail. Take home message. There's no perfect measure of inequality. There's lots and lots of measures, and they're all tapping a little bit different nuance of this idea of unequal. Inequality, however measure you're going to use is always complicated and it's usually politically charged. So, be a little cautious, realize that its complicated and the questions; such as, reference point, to whom are we comparing, we doing individuals or groups, these things really matter. The summary measures always entail ethical or value judgments. This is not a bad thing, but I want you to appreciate that when you pick or choose or read a given measure of inequality, it inherently entails some value judgement, some deviation from equality which is ethical. And finally, much like our discussion of measuring race. I want to encourage you to be humble, to be cautious when using, when thinking about or when reading others work on measures of inequality.