2005. 312 pp. $58. The need to eliminate health disparities in the. United States is being supported increasingly by ... national, state, and local public health efforts to eliminate disparities. ... Associate Professor. Department of Public Health.
Book Review
Vulnerable Populations in the United States. By Leiyu Shi and Gregory D. Stevens. San Francisco: Jossey-Bass/A Wiley Imprint. 2005. 312 pp. $58. The need to eliminate health disparities in the United States is being supported increasingly by public health researchers and practitioners. Indeed, one of the goals of Healthy People 2010 is to eliminate health disparities and, according to a 1999 U.S. Commission on Civil Rights Report to the President and Congress, ‘‘failure to recognize and eliminate differences in health care delivery, financing, and research presents a discriminatory barrier that creates and perpetuates differences in health status.’’ It is, therefore, not surprising to find a growing number of books on the topic of health disparities that include discussion on the causes and factors of disparities and on strategies to eliminate them. Vulnerable Populations in the United States is such a book. In the introduction, the authors point out their intention to give a new perspective on the causes of ‘‘disparities in access, quality, and health status of the nation’s vulnerable populations,’’ and to provide scientists and practitioners with a framework in which to study and target health disparities. Further, they offer to ‘‘propose a new course of action’’ in which to eliminate health disparities among the most vulnerable of populations. Although many terms have been used to describe people disproportionately affected by health disparities, Shi and Stevens have chosen to use the term ‘‘vulnerable populations.’’ Vulnerable, for the purpose of this book, refers to populations of minority racial/ethnic backgrounds, of low socioeconomic status (SES),
and of those lacking health insurance. The authors contend that these are, indeed, the most vulnerable populations in the United States—ones most at risk for health disparities. The book is nicely organized; it begins with a description of a general framework to study disparities and proceeds to a discussion on the community-related factors that contribute to disparities. Following are chapters on health care disparity data related to individual and multiple risk factors, a thorough description of current strategies, and a final framework to eliminate disparities. The framework described in Chapter 1 sets the stage for the entire book, which remains focused on strategies and methods to increase equality in health. Unlike other books on health disparities among racial and ethnic minorities, Vulnerable Populations in the United States takes an ecological approach to understanding inequalities and disparities. It is a welcome relief that the authors talk about individual and social factors, and do not describe solely the specific behavioral factors that occur within racial and ethnic groups. Although understanding cultural aspects of health is critical and a part of an ecological approach, it places the onus on the individual to make changes, not on society, the health care system, and policymakers. In their book, Shi and Stevens fully develop the ecological aspect of their framework by including such factors of disparities as: geographical location; neighborhood composition; cultural and social norms (i.e., religion); political, legal, and health care systems; SES, social class, and social capital; health trends; and others. One of the most valuable aspects of the book is the comprehensive framework the authors have developed, taking into account factors in the
Inquiry 43: 179–181 (Summer 2006). Ó 2006 Excellus Health Plan, Inc. 0046-9580/06/4302–0179 www.inquiryjournal.org
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physical and social environment. To further help readers understand their framework, the authors present a thorough review of existing models of health disparities. After describing their ‘‘vulnerability framework,’’ the authors spend the next three chapters outlining the major disparity issues facing vulnerable populations and the risk factors (both individual and multiple) that cause health disparities. Much of the information presented here can be found in other books on health disparities; however, as mentioned earlier, these chapters provide depth and insight into their framework. The final chapters are really how this book differs from other texts on health disparities. Chapter 5 provides a comprehensive and useful review of the descriptions, strengths, and weaknesses of national, state, and local public health efforts to eliminate disparities. The book’s final chapter presents a framework to target and eliminate health disparities; it includes several points of intervention, the use of a community participatory approach, a focus on an ecological outlook, and a 10-step process to follow. In sum, Vulnerable Populations in the United States provides a comprehensive and reasonable approach to understanding and eliminating health disparities. One major weakness of the book is its narrow view of vulnerable populations. Indeed, racial and ethnic minorities experience a disproportionate level of health disparities; however, we should not ignore disparities within other populations that are in need of our attention (i.e., lesbian, gay, bisexual, and transgender individuals, persons with disabilities, and the elderly). Despite this, Vulnerable Populations is a very worthwhile read for health care administrators, health policy analysts, public health and health promotion practitioners, students of public health, and health researchers. As a professor of public health, I find this to be a useful text for both undergraduate and graduate students of community health assessment, program planning, multicultural health, and health education interventions.
Jean M. Breny Bontempi, Ph.D. Associate Professor Department of Public Health School of Health and Human Services Southern Connecticut State University, New Haven 180
Medicine and the Market: Equity v. Choice. By Daniel Callahan and Angela A. Wasunna. Baltimore: The Johns Hopkins University Press. 2006. 334 pp. $35 (hardcover). It’s no secret that understanding modern health care is a difficult task and that the subject itself contains many controversies. From an ethical standpoint, it’s interesting that many would agree on a few basic concerns. Most would acknowledge that the existence of a large uninsured population is hard to defend, as are disparities in access to basic health care. The difficulties arise in deciding how to deal with these situations. Market-based reformers argue that health care should be subjected more to market forces. Consumers, for example, should not be totally shielded from the actual costs of health care. Those advocating universal health care tend to focus on the unique attributes of the health sphere and claim that health care is a right and not a commodity. On this view, market forces should not be allowed to interfere with this right. Daniel Callahan and Angela Wasunna are universal health care proponents who, nonetheless, seek to understand what market forces may have to offer to equitable health care delivery. One of the many virtues of Medicine and the Market is that the authors forthrightly state their support for universal, equitable access that is either government-run or supervised. They write that this support strengthened as their research progressed. The book offers an assessment of health care delivery in various countries and how market forces either have or have not contributed to the equity and effectiveness of this delivery. Not surprisingly, the authors find much good in the European and Canadian models, and tend to discount supposed issues with these government-based approaches. For example, they note the well-known Canadian problem of long waiting lists for procedures, but say the actual impact ‘‘may not be as great as many imagine.’’ Such approaches compare favorably to the United States where waiting lists are ‘‘hardly unknown’’ and where there is a continuing struggle to find a politically acceptable balance between public and private mechanisms. Although the comprehensive scope of the work is commendable, it might have achieved its aims better had the authors stayed closer to a strict scientific approach. In other words, it
