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Public Health. 2017 Aug;149:149-158. doi: 10.1016/j.puhe.2017.04.015. Epub 2017 Jun 20.

A paradigm shift for socioeconomic justice and health: from focusing on inequalities to aiming at sustainable equity.

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University of California Berkeley, Center of Global Public Health, Berkeley, CA, USA.
University of Massachusetts Medical School, 55 Lake Ave North, Worcester, MA 01655, USA. Electronic address:



To measure the 'best possible health for all', incorporating sustainability, and to establish the magnitude of global health inequity.


Observational, retrospective.


We identified countries with three criteria: (1) a healthy population-life expectancy above world average; (2) living conditions feasible to replicate worldwide-per-capita gross domestic product (GDP-pc) below the world average; and (3) sustainability-per-capita carbon dioxide emissions lower than the planetary pollution boundary. Using these healthy, feasible, and sustainable (HFS) countries as the gold standard, we estimated the burden of global health inequity (BGHiE) in terms of excess deaths, analyzing time-trends (1950-2012) by age, sex, and geographic location. Finally, we defined a global income 'equity zone' and quantified the economic gap needed to achieve global sustainable health equity.


A total of 14 countries worldwide met the HFS criteria. Since 1970, there has been a BGHiE of ∼17 million avoidable deaths per year (∼40% of all deaths), with 36 life-years-lost per excess death. Young children and women bore a higher BGHiE, and, in recent years, the highest proportion of avoidable deaths occurred in Africa, India, and the Russian Federation. By 2012, the most efficient HFS countries had a GDP-pc/year of USD$2,165, which we proposed as the lower equity zone threshold. The estimated USD$2.58 trillion economic gap represents 3.6% of the world's GDP-twenty times larger than current total global foreign aid.


Sustainable health equity metrics provide a benchmark tool to guide efforts toward transforming overall living conditions, as a means to achieve the 'best possible health for all.'


Benchmarking; Gross domestic product; Health equity; International cooperation; Life expectancy; Sustainability

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