Vulnerable Populations in the United States
http://www.100md.com
《新英格兰医药杂志》
Recent findings and trends associated with health disparities, along with their causes, consequences, and potential solutions, are reviewed in Vulnerable Populations in the United States. It is an excellent primer for undergraduates and graduate students in public health and for medical students interested in vulnerable populations and health disparities.
The first chapter introduces a general conceptual framework for studying vulnerable populations. After reviewing the many models in the literature that have helped elucidate the social and behavioral determinants of health, Shi and Stevens propose a model of vulnerability that has been developed as an interaction of risk factors, access to care, and quality of care. Risk factors are characterized as both individual and ecologic and identified on three levels: predisposing factors, enabling factors, and need. The model moves beyond familiar approaches by emphasizing multiple interactions both conceptually and in some of the analyses presented later in the book.
Although the conceptual approach used in this study is useful for understanding patterns of health, it has limited use as an approach to health outcomes. Risk factors are particular for specific illnesses, impairments, and deaths that are not specified by general models. As public health and medicine work to heal the long-standing schism that currently weakens both disciplines, we must move beyond general models to a more specific understanding of the determinants of health outcomes and disease states.
The book focuses on three key areas associated with vulnerability and health disparities: race and ethnic background, social and economic status, and insurance-coverage status. These factors structure the subsequent chapters presenting the determinants of vulnerability, the empirical literature that documents and explains disparities, and the relationship between multiple risk factors. It is refreshing that the authors do not try to reduce any one of the key factors to the others or suggest that one is more important or explains the others. Race and ethnic background, social class, and health insurance coverage are inextricably linked in the history of the United States and in the health of its people.
Most welcome in this book is a chapter that joins the patterns and causes of vulnerability in a description of the programs of public health and medicine that address disparities. Shi and Stevens analyze programs for validity, scope and reach, sustainability, and effectiveness. This chapter is uneven in its treatment of the programs in somewhat surprising ways. For example, the history of Medicare and Medicaid — billion-dollar programs that were created to address health disparities — get one line, whereas some small local programs are described in several paragraphs. The chapter also neglects the history of the effort to link local and philanthropic health systems that has been so critical to the safety net of this country. The change in that system is critical to understanding the current uninsured status of 45 million people.
The last chapter is devoted to resolving health disparities in the United States, beginning with a description of Healthy People 2010, a federal initiative that sets goals for national efforts to improve the health of Americans, including the identification of preventable threats. A wide variety of strategies are discussed, ranging from the very specific (cultural competence in health care) to broad social reforms, such as income redistribution and single-payer health insurance. The book ends on a refreshingly positive note of activism, outlining concrete steps to help eliminate health disparities that students and practitioners can take seriously.
We should look forward to many new editions of this book as the drama of health disparities in our nation continues to unfold. Subsequent editions might be improved by including a discussion of cultural competence in primary-prevention programs. Smoking rates have dramatically decreased among highly educated Americans but have changed very little among the least educated. This growing gap suggests that our smoking-cessation programs may not have been attuned to the realities of all social classes in the United States. A later edition might also take into account that we have become an increasingly global society.
Gregory Pappas, M.D., Ph.D.
Johns Hopkins Bloomberg School of Public Health
Baltimore, MD 21205
greg_pappas@hotmail.com
The first chapter introduces a general conceptual framework for studying vulnerable populations. After reviewing the many models in the literature that have helped elucidate the social and behavioral determinants of health, Shi and Stevens propose a model of vulnerability that has been developed as an interaction of risk factors, access to care, and quality of care. Risk factors are characterized as both individual and ecologic and identified on three levels: predisposing factors, enabling factors, and need. The model moves beyond familiar approaches by emphasizing multiple interactions both conceptually and in some of the analyses presented later in the book.
Although the conceptual approach used in this study is useful for understanding patterns of health, it has limited use as an approach to health outcomes. Risk factors are particular for specific illnesses, impairments, and deaths that are not specified by general models. As public health and medicine work to heal the long-standing schism that currently weakens both disciplines, we must move beyond general models to a more specific understanding of the determinants of health outcomes and disease states.
The book focuses on three key areas associated with vulnerability and health disparities: race and ethnic background, social and economic status, and insurance-coverage status. These factors structure the subsequent chapters presenting the determinants of vulnerability, the empirical literature that documents and explains disparities, and the relationship between multiple risk factors. It is refreshing that the authors do not try to reduce any one of the key factors to the others or suggest that one is more important or explains the others. Race and ethnic background, social class, and health insurance coverage are inextricably linked in the history of the United States and in the health of its people.
Most welcome in this book is a chapter that joins the patterns and causes of vulnerability in a description of the programs of public health and medicine that address disparities. Shi and Stevens analyze programs for validity, scope and reach, sustainability, and effectiveness. This chapter is uneven in its treatment of the programs in somewhat surprising ways. For example, the history of Medicare and Medicaid — billion-dollar programs that were created to address health disparities — get one line, whereas some small local programs are described in several paragraphs. The chapter also neglects the history of the effort to link local and philanthropic health systems that has been so critical to the safety net of this country. The change in that system is critical to understanding the current uninsured status of 45 million people.
The last chapter is devoted to resolving health disparities in the United States, beginning with a description of Healthy People 2010, a federal initiative that sets goals for national efforts to improve the health of Americans, including the identification of preventable threats. A wide variety of strategies are discussed, ranging from the very specific (cultural competence in health care) to broad social reforms, such as income redistribution and single-payer health insurance. The book ends on a refreshingly positive note of activism, outlining concrete steps to help eliminate health disparities that students and practitioners can take seriously.
We should look forward to many new editions of this book as the drama of health disparities in our nation continues to unfold. Subsequent editions might be improved by including a discussion of cultural competence in primary-prevention programs. Smoking rates have dramatically decreased among highly educated Americans but have changed very little among the least educated. This growing gap suggests that our smoking-cessation programs may not have been attuned to the realities of all social classes in the United States. A later edition might also take into account that we have become an increasingly global society.
Gregory Pappas, M.D., Ph.D.
Johns Hopkins Bloomberg School of Public Health
Baltimore, MD 21205
greg_pappas@hotmail.com