Vulnerable Populations in the United States (review)

This book calls attention to the inequalities in health and health care experiences between vulnerable populations and those of the majority in the U.S. It enhances existing literature both by providing an overview of this vast subject and by supplying an integrated framework for the study of vulnerable populations. It makes clear that, for political, social, and economic (as well as moral) reasons, the country must increasingly make vulnerable populations a national health policy priority.

To begin with a bird's eye view, the book is organized into six chapters. The first chapter discusses the definition and measures used in a general conceptual framework for studying vulnerable populations, one that draws very different groups (racial and ethnic minorities, the uninsured, children, the elderly, the poor, the chronically ill, people with acquired immunodeficiency syndrome (AIDS), alcohol or substance abusers, people who are homeless, underserved rural groups, underserved urban groups, people who do not speak English or who have other difficulties in communicating in health care setting, and those who are poorly educated or illiterate) under one umbrella. Vulnerable populations are identified here as all of those with low incomes or disabilities or who are members of minority groups.

Chapter Two examines the determinants of vulnerability using a broad conceptual framework that includes both social and individual determinants, and explains the mechanisms through which vulnerability affects access to health care and health care quality as well as health status. In Chapters Three and Four, existing literature is summarized and empirical evidence of health disparities is provided, with emphases on socioeconomic status (SES), health insurance, and race/ethnicity. Chapter Five reviews current programs available to vulnerable populations, discusses how the mechanisms of vulnerability are addressed by these programs, and systematically critiques their potential to improve health care access and quality, and the health of vulnerable populations. Chapter Six outlines new strategies to reduce or eliminate disparities.

There is no consensus concerning what constitutes vulnerable populations, despite extensive research and efforts at reducing disparities in health and health care between numerous vulnerable groups and the general public. In general, medicine recognizes vulnerability in susceptibility to poor health, while research and policy focus on distinct vulnerable populations socio-demographically.

Shi and Stevens review the many reasons to focus national attention on the health needs of vulnerable populations, including these: (1) Vulnerable populations have greater health needs; are at substantially greater risk of poor physical, mental, and social health; and have much higher rates of morbidity and mortality than the general population. They also typically face greater barriers to accessing timely and needed care and even receiving care and have worse health outcomes than others. (2) The proportion of the U.S. population that is medically vulnerable is increasing as a result of demographic shifts and socioeconomic trends in both the U.S. and other nations; it is likely that groups making up the medically vulnerable now will constitute the majority population before the end of the 21^st century. (3) Vulnerability is primarily a social matter, created through social forces and resolved through social (as opposed to individual) means; it does not reflect personal deficiency but structural social forces over which most individuals have little or no control. Building on this point, the authors argue a point made with increasing frequency in public health that effectively lessening vulnerability and mitigating its consequences demands broad health and social policies that address these societal forces and the ecological context of health. (4) Vulnerability is intertwined with the nation's health resources; fundamental improvement of the nation's health and resources cannot be accomplished without very specific efforts aimed at improving the health of vulnerable populations. (5) If equity is the principle that guides public health policy, eliminating disparities in health and health care must be the policy's central concern.

The authors effectively review public health models of vulnerability, including Aday's resilient and influential Individual Social Resources Model, which represents how...