Medical Management of Vulnerable and Underserved

Patients: Principles, Practice, Populations, Second Edition

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Section Editors

PRINCIPLES

Andrew B. Bindman, MD
Professor, Department of Medicine, School of Medicine
University of California , San Francisco
San Francisco, California

Kevin Grumbach, MD
Professor and Chair, Department of Family and Community
Medicine, School of Medicine
University of California , San Francisco
Priscilla Chan and Mark Zuckerberg San Francisco General
Hospital and Trauma Center
San Francisco, California

PRACTICE

Alicia Fernandez, MD
Professor, School of Medicine
University of California , San Francisco
Priscilla Chan and Mark Zuckerberg San Francisco
General Hospital and Trauma Center
San Francisco, California

Dean Schillinger, MD
Professor and Chief, Division of General Internal Medicine
Priscilla Chan and Mark Zuckerberg San Francisco
General Hospital and Trauma Center
University of California San Francisco
Center for Vulnerable Populations
School of Medicine
San Francisco, California

POPULATIONS

Teresa J. Villela, MD
Professor and Vice Chair, Department of Family Community
Medicine
School of Medicine
University of California San Francisco
Chief of Service, Department of Family Community Medicine
Priscilla Chan and Mark Zuckerberg San Francisco
General Hospital and Trauma Center
San Francisco, California

Margaret B. Wheeler, MD, MS

Professor, Department of Medicine
School of Medicine
University of California San Francisco
Priscilla Chan and Mark Zuckerberg San Francisco
General Hospital and Trauma Center
San Francisco, California
 Me dical Manage m e nt o f
Vulne rable and Unde rs e rve d
Patie nts
Prin cip le s , Pra ctice , a n d Po p u la tio n s
Se co n d Ed itio n

Talmadge E. King, Jr., MD

Dean, School of Medicine
Vice Chancellor-Medical Affairs
University of California , San Francisco
San Francisco, California

Margaret B. Wheeler, MD, MS

Professor, School of Medicine
University of California , San Francisco
Priscilla Chan and Mark Zuckerberg San Francisco
General Hospital and Trauma Center
San Francisco, California

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Medical Management of Vulnerable and Underserved Patients: Principles, Practice, and
Populations, Second Edition

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Library of Congress Cataloging-in-Publication Data

Names: King, almadge E., Jr., editor. | Wheeler, Margaret B., editor.
itle: Medical management o vulnerable and underserved patients :
principles, practice, and populations / [edited by] almadge E. King, Jr.,
Margaret B. Wheeler.
Description: Second edition. | New York : McGraw Hill Education Medical,
[2016] | “A Lange medical book.” | Includes bibliographical re erences and index.
Identif ers: LCCN 2015046071| ISBN 9780071834445 (pbk. : alk. paper) | ISBN
0071834443 (pbk. : alk. paper) | ISBN 9780071834018 (ebook) | ISBN
007183401X (ebook)
Subjects: | MESH: Delivery o Health Care | Vulnerable Populations | Health
Services Accessibility | Minority Groups | Medical Indigency | Health
Services Needs and Demand | United States
Classif cation: LCC RA418.5.P6 | NLM W 84 AA1 | DDC 362.1/0425—dc23 LC record available at
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 Talmadge E. King, Jr.:
I thank Mozelle for her love, support, and encouragement and to Talmadge and Almetta
King for teaching me the value of hard work and education. In addition, I thank my
daughters, Consuelo and Malaika , for their loving support and my granddaughters,
Madison and Siena , for keeping it real.

Margaret B. Wheeler:
To my patients and teachers for their guidance and nurturing, my students and
colleagues for their inspiration, and my family for unstinting support.

Andrew B. Bindman:
I thank my parents, Arthur and Bernice, who have encouraged me to contribute toward
making a constructive difference in people’s lives. I also thank my wife, Rebecca and our
three wonderful children, Sarah, Julia , and Jacob, who have made an enormous positive
impact on my own life.

Alicia Fernandez:
To the memory of my parents, Hector and Paulina B. Fernandez. De tal árbol,
tal a stilla .

Kevin Grumbach:
With appreciation to my family, colleagues, students, and patients, for all they have
taught me.

Dean Schillinger:
I thank George Schillinger for demonstrating the potential for resilience in the face
of vulnerability and for imbuing me with a belief that doctoring requires the head,
hands, and heart; Zahava Schillinger for instilling in me the confidence and diligence
to accomplish my goals; Nahum Joel for conveying his pa ssion regarding science and
the pursuit of social justice; Ariella Hyman for partnering with me in this struggle; and
Eytan, Gabriel, and Micaela , who, when work becomes overwhelming, always bring me
back to the simple joys of life.

Teresa J. Villela:
To Amado, Carolina , Elvira , Marcelo, Florentina , Gilberto, and Rosario, with great
respect and gratitude, and to my brothers and sisters for all they have taught me.
Co nte nts

Contributors ix 8. Advo cacy 79

Preface xvii Ricky Y. Choi, MD, MPH, Laura Gottlieb, MD, MPH,
and Alice Hm Chen, MD, MPH

PART 1 PRINCIPLES 1
PART 2 PRACTICE 89
1. Vulne rable Po pulatio ns , He alth
9. Practical S trate g ie s in Addre s s ing
Dis paritie s , and He alth Equity: An Ove rvie w 2
S o cial De te rm inants o f He alth in
Kevin Grumbach, MD, Paula Braveman, MD, MPH,
Nancy Adler, PhD, and Andrew B. Bindman, MD Clinical S e tting s 90
Laura Gottlieb, MD, Rishi Manchanda , MD,
and Megan Sandel, MD
2. He alth-Care Dis paritie s : An Ove rvie w 13
Andrew B. Bindman, MD, Kevin Grumbach, MD, and
Bruce Guthrie, MB, BChir, PhD 10. Cre ating a Co nte xt fo r Effe ctive
Inte rve ntio n in the Clinical Care
o f Vulne rable Patie nts 104
3. Financing and Organizatio n o f Dean Schillinger, MD, Neda Ratanawongsa , MD,
He alth Care fo r Vulne rable Po pulatio ns 25 MPH, Teresa Villela , MD, and George William
Christopher B. Forrest, MD, PhD, Jessica E. Saba , PhD
Hawkins, MSE, and Ellen-Marie Whelan, NP, PhD

11. Cre ating the Me dical Ho m e fo r

4. Le gal Is s ue s in the Care o f
Unde rs e rve d Patie nts 115
Unde rs e rve d Po pulatio ns 35
Reena Gupta , MD, and Thoma s Bodenheimer, MD
Sara Rosenbaum, JD

5. Principle s in the Ethical Care o f 12. Pro m o ting Be havio r Change 124
Unde rs e rve d Patie nts 49 Jennifer E. Hettema , PhD, Christopher Neumann,
Bernard Lo, MD and Robert V. Brody, MD PhD, Bradley Samuel, PhD, Daniel S. Lessler, MD,
MHA, and Christopher Dunn, PhD

6. Co m m unity Engage m e nt and Partne rs hip 60

Naomi Wortis, MD and Ellen Beck, MD 13. As s e s s ing and Pro m o ting Me dicatio n
Adhe re nce 137
Sharon L. Youmans, PharmD, MPH,
7. A Glo bal Pe rs pe ctive o n the Care o f and Kirsten Bibbins-Domingo, MD, PhD
Me dically Vulne rable and Unde rs e rve d
Po pulatio ns 69
Stephanie Taché, MD, MPH, Sarah Macfarlane, MSc, 14. Navigating Cro s s -Cultural Co m m unicatio n 149
PhD, Megan Mahoney, MD, and Kevin Grumbach, MD JudyAnn Bigby, MD and Alicia Fernandez, MD

vi
 Contents v ii

15. Im proving the Co m m unicatio n Exchange : 25. Wo rk, Living Enviro nm e nt,
A Fo cus o n Lim ite d He alth Lite racy 159 and He alth 277
Debra Keller, MD, MPH, Urmimala Sarkar, MD, Michael Guarnieri, MD, Janet Victoria Diaz, MD,
MPH, and Dean Schillinger, MD and John R. Balmes, MD

16. Gro up Me dical Vis its fo r Unde rs e rve d 26. Care o f the Fo o d Ins e cure Patie nt 289
Po pulatio ns 168 Hilary Seligman, MD, MAS and Jona s Hines, MD
Pooja Mittal, DO, Hali Hammer, MD,
and Margaret Hutchison, CNM
27. Clinical Care fo r Pe rs o ns w ith a His to ry
o f Incarce ratio n 299
17. Applying Inte ractive Mo bile He alth Emily H. Thoma s, MD, Nathan Birnbaum, BA,
(m He alth) Te chno lo g ie s fo r Vulne rable Jacqueline P. Tulsky, MD, and Emily A. Wang, MD, MAS
Po pulatio ns 180
Courtney R. Lyles, PhD, Dean Schillinger, MD, 28. Care o f the Ho m e le s s Patie nt 311
and John D. Piette, PhD Margot Kushel, MD and Sharad Jain, MD

18. Applying Principle s and Practice o f 29. Im m ig rant He alth Is s ue s 320

Quality Im prove m e nt fo r Be tte r Care Margaret Wheeler, MD, Teresa J. Villela , MD,
o f the Unde rs e rve d 193 and Susana Morales, MD
Claire Horton, MD, MPH, Urmimala Sarkar, MD,
MPH, and Alicia Fernandez, MD
30. Rural He alth Care : Co m m unitie s , Sys te m s ,
and Patie nt Care 332
19. Inte rdis ciplinary Mo de ls o f Care fo r David V. Evans, MD, Toby Keys, MPH,
Hig h-Ris k Patie nts 204 and Steven Meltzer, PA-C
Michelle Schneidermann, MD and Elizabeth
Davis, MD
31. Providing Care to Patie nts Who S pe ak
Lim ite d Eng lis h 343
Alice Hm Chen, MD, MPH, Elizabeth A. Jacobs,
PART 3 POPULATIONS 213 MD, MPP, and Alicia Fernandez, MD

20. Unde rs e rve d Childre n: Pre ve nting Chro nic

Illne s s and Pro m o ting He alth 214 32. The Care o f Le s bian, Gay, Bis e xual, and
Patricia Barreto, MD, MPH, Joanna Mimi Choi, MD, Trans ge nde r Patie nts 353
and Neal Halfon, MD, MPH Anne Rosenthal, MD, Patricia Robertson, MD,
Shane Snowdon, MA, and Barry Zevin, MD

21. Vulne rabilitie s o f Ado le s ce nce and Yo ung

Adultho o d 226 33. The Me dical Tre atm e nt o f Patie nts w ith
Erica Mona sterio, MN, FNP-BC, Ellen M. Scarr, Ps ychiatric Illne s s 366
PhD, FNP-BC, Naomi Schoenfeld, MS, FNP-BC, Christina Mangurian, MD, J. Ryan Shackelford, MD,
and William B. Shore, MD and James W. Dilley, MD

22. The Fam ily as the Co nte xt fo r Care 245 34. Wo m e n’s He alth: Re pro ductio n and
George William Saba , PhD and Teresa J. Villela , MD Beyo nd in Po o r Wo m e n 381
Elizabeth Harleman, MD, Carolyn Payne, MD,
and Jody Steinauer, MD, MAS
23. The Hidde n Po o r: Care o f the
Olde r Adult 254
Katrina Booth, MD, C. Seth Landefeld, MD, 35. Intim ate Partne r Vio le nce 395
and Helen Chen, MD Palav Babaria , MD, MHS, Brigid McCaw, MD, MS,
MPH, and Leigh Kimberg, MD

24. Care o f the Dying Patie nt 265

Jeffrey Stoneberg, DO, Tracy Schrider, LCSW, 36. Traum a and Traum a-Info rm e d Care 408
ACM, and LaVera M. Crawley, MD, MPH Leigh Kimberg, MD
v iii Contents

37. Obe s ity as a Clinical and S o cial Pro ble m 425 42. Dis ability and Patie nts w ith Dis abilitie s 494
Ann Smith Barnes, MD, MPH, Marisa Rogers, Lisa I. Iezzoni, MD, MSc, and Margot Kushel, MD
MD, MPH, and Cam-Tu Tran, MD, MS

43. HIV/ AIDS : Im pact o n Vulne rable

38. Chro nic Pain Manage m e nt in Po pulatio ns 507
Vulne rable Po pulatio ns 438 Ronald H. Goldschmidt, MD, Joanna Eveland, MD,
Soraya Azari, MD, Barry Zevin, MD, and Jacqueline P. Tulsky, MD
and Michael B. Potter, MD

44. Care o f the S o cially Co m plicate d

39. Principle s o f Caring fo r Pe o ple Who Patie nt in the Ho s pital 518
Us e Alco ho l and Othe r Drug s 452 Margaret Stafford, MD, Leslie Dubbin, RN, PhD,
Alexander Y. Walley, MD, MSc Lawrence Haber, MD, and Jeff Critchfield, MD

40. To bacco Us e 463 45. Caring fo r Ours e lve s While Caring

Maya Vijayaraghavan, MD, MAS, fo r Othe rs 532
and Steven A. Schroeder, MD Diana Coffa , MD

41. De ntal Care : The Fo rgo tte n Ne e d 478

Index 544
Francisco Ramos-Gomez, DDS, MS, MPH, Carolyn
Brown, DDS, and Susan Fisher-Owens, MD, MPH
Co ntributo rs

Nancy Adler, PhD Ellen Beck, MD

Director, Center for Health and Community Professor of Medicine,
Professor, Department of Psychiatry Department of Medicine, Division of General Internal
School of Medicine Medicine (DGIM)
University of California San Francisco (UCSF) School of Medicine, University of California San Francisco
San Francisco, California Priscilla Chan and Mark Zuckerberg San Francisco General
Hospital and Trauma Center
Soraya Azari, MD San Francisco, California

Assistant Clinical Professor of Medicine Kirsten Bibbins-Domingo, PhD, MD, MAS

Division of General Internal Medicine (DGIM), Priscilla Chan
and Mark Zuckerberg San Francisco General Hospital and Lee Goldman, MD Endowed Chair in Medicine
Trauma Center Professor of Medicine and of Epidemiology and Biostatistics
University of California San Francisco School of Medicine, University of California San Francisco
San Francisco, California San Francisco, California

Palav Babaria, MD, MHS JudyAnn Bigby, MD

Medical Director, Highland Hospital Adult Medicine Clinic Senior Fellow

Alameda Health System Mathematica Policy Research
Oakland, California Cambridge, Ma ssachusetts
Assistant Clinical Professor, Department of Medicine
Andrew B. Bindman, MD
University of California San Francisco
San Francisco, California Professor
Department of Medicine
John R. Balmes, MD School of Medicine
University of California San Francisco (UCSF)
Professor, Department of Medicine
San Francisco, California
University of California , San Francisco
Professor, School of Public Health Nathan Birnbaum B.A.
University of California , Berkeley
Medical Student
Ann Smith Barnes, MD, MPH School of Medicine
University of California , Irvine
Associate Professor, Irvine, California
Department of Medicine
Baylor College of Medicine Thomas Bodenheimer, MD
Houston, Texa s
Department of Family and Community Medicine
Patricia Barreto, MD, MPH Priscilla Chan and Mark Zuckerberg San Francisco General
Hospital and Trauma Center
Senior Research Scientist University of California , San Francisco
UCLA Center for Healthier Children, Families & Communities San Francisco, California

ix
x Contributors

Katrina Booth, MD Diana Coffa, MD

Assistant Professor Residency Program Director, Family and Community Medicine
Medical Director, Acute Care for Elders (ACE) Unit Assistant Professor
Division of Gerontology, Geriatrics, and Palliative Care Department of Family and Community Medicine
University of Alabama at Birmingham School of Medicine
Birmingham VA Medical Center University of California San Francisco
Birmingham, Alabama Priscilla Chan and Mark Zuckerberg San Francisco
General Hospital and Trauma Center
San Francisco, California
Paula Braveman, MD, MPH
Professor, Department of Family Community Medicine
LaVera Crawley, MD, MPH, MDiv(Eq)
School of Medicine, University of California San Francisco
San Francisco, California Program Manager for Palliative Care Education
and Research;
Palliative Care Chaplain, Alta Bates Summit
Robert V. Brody, MD Medical Center
Professor, Department of Medicine, Division of General Internal Berkeley, California
Medicine (DGIM) School of Medicine
University of California San Francisco
Jeff Critchfield, MD
Priscilla Chan and Mark Zuckerberg San Francisco
General Hospital and Trauma Center Professor, Department of Medicine, University of California
San Francisco, California San Francisco School of Medicine;
Chief Medical Experience Officer and Medical Director of
Risk Management, Priscilla Chan and Mark Zuckerberg
Carolyn Brown, DDS
San Francisco General Hospital;
Dental Director, Programs and Development Professor, Department of Medicine, Division of Hospital
San Francisco Native American Health Center Medicine,
San Francisco, California School of Medicine,
University of California San Francisco
Priscilla Chan and Mark Zuckerberg San Francisco
Helen Chen, MD General Hospital and Trauma Center
Chief Medical Officer, Hebrew Rehabilitation San Francisco, California
Center/ Hebrew Senior Life
Boston, Ma ssachusetts
Elizabeth Davis, MD
Director of Care Coordination, San Francisco Health Network
Alice Hm Chen, MD, MPH Primary Care, San Francisco, California
Chief Medical Officer, San Francisco Health Network; Assistant Professor
Professor of Medicine, Division of General Internal Medicine (DGIM),
School of Medicine, Division of General Internal Medicine School of Medicine
(DGIM) University of California San Francisco
University of California San Francisco Priscilla Chan and Mark Zuckerberg San Francisco
Priscilla Chan and Mark Zuckerberg San Francisco General Hospital and Trauma Center
General Hospital and Trauma Center San Francisco, California
San Francisco, California
Janet Victoria Diaz, MD
Ricky Y. Choi, MD, MPH
Consultant, Pulmonary and Critical Care Medicine
Department Head of Pediatrics, Asian Health Services California Pacific Medical Center
Community Health Center San Francisco, California
Oakland, California
James W. Dilley, MD
Joanna Mimi Choi, MD, MPH
Professor, Department of Psychiatry
Assistant Professor, Department of Pediatrics School of Medicine, University of California
UCLA Fielding School of Public Health San Francisco
Los Angeles, California San Francisco, California
 Contributors xi

Leslie Dubbin, PhD, MS, RN Laura Gottlieb, MD, MPH

Assistant Adjunct Professor, Department of Social and Department of Family and Community Medicine,
Behavioral Sciences School of Medicine, University of California San Francisco,
School of Nursing, University of California San Francisco San Francisco, California
San Francisco, California
Kevin Grumbach, MD
Christopher Dunn, PhD
Professor and Chair, Department of Family and Community
Associate Professor Medicine,
Psychiatry and Behavioral Sciences School of Medicine, University of California San Francisco,
University of Wa shington San Francisco, California
Seattle, Wa shington
Michael Guarnieri, MD, MPH
David V. Evans, MD
Fellow, Division of Pulmonary Medicine,
Rosenblatt Family Endowed Professor of Rural Health, Associate School of Medicine, University of California San Francisco,
Professor, Department of Family Medicine, University of San Francisco, California
Wa shington School of Medicine, Seattle, Wa shington
Reena Gupta, MD
Joanna Eveland, MD
Assistant Professor of Medicine,
Department of Family and Community Medicine, Department of Medicine
School of Medicine, University of California San Francisco, Division of General Internal Medicine (DGIM)
Priscilla Chan and Mark Zuckerberg San Francisco School of Medicine
General Hospital and Trauma Center University of California San Francisco
San Francisco, California Priscilla Chan and Mark Zuckerberg San Francisco
General Hospital and Trauma Center
Alicia Fernandez, MD San Francisco, California

Professor, Department of Medicine,

Bruce Guthrie, MB, BChir, PhD
Division of General Internal Medicine (DGIM),
School of Medicine Professor of Primary Care Medicine, Population Health Sciences
University of California San Francisco Division,
Priscilla Chan and Mark Zuckerberg San Francisco University of Dundee, Dundee, Scotland.
General Hospital and Trauma Center
San Francisco, California Lawrence A. Haber, MD
Assistant Professor, Department of Medicine,
Susan Fisher-Owens, MD, MPH
School of Medicine, University of California San Francisco,
Associate Clinical Professor of Pediatrics; Associate Clinical Priscilla Chan and Mark Zuckerberg San Francisco
Professor of Preventive and Restorative Dental Sciences, General Hospital and Trauma Center
School of Medicine, Division of General Internal Medicine San Francisco, California
(DGIM)
University of California San Francisco Neal Halfon, MD, MPH
Priscilla Chan and Mark Zuckerberg San Francisco
Professor, Department of Pediatrics, Department of Health
General Hospital and Trauma Center
Policy and Management, UCLA Geffen School of Medicine;
San Francisco, California
UCLA Fielding School of Public Health, Department of Health
Policy and Management; UCLA Luskin School of Public Affairs,
Christopher B. Forrest, MD, PhD
Department of Public Policy; Director, UCLA Center for Healthier
Professor of Pediatrics and Health Care Management, Children Families and Communities, Los Angeles, California
Children’s Hospital of Philadelphia and the University of
Pennsylvania School of Medicine, Philadelphia , Pennsylvania Hali Hammer, MD
Director of Primary Care
Ronald H. Goldschmidt, MD
San Francisco Department of Public Health
Professor, Department of Family and Community Medicine Professor Family and Community Medicine, School of Medicine
School of Medicine, University of California San Francisco University of California San Francisco
Priscilla Chan and Mark Zuckerberg San Francisco Priscilla Chan and Mark Zuckerberg San Francisco
General Hospital and Trauma Center General Hospital and Trauma Center
San Francisco, California San Francisco, California
x ii Contributors

Elizabeth Harleman, MD Sharad Jain, MD

Professor, Departments of Medicine and Obstetrics, Gynecology Professor, Department of Medicine,
and Reproductive Sciences, School of Medicine, University of California San Francisco,
School of Medicine, University of California San Francisco, Priscilla Chan and Mark Zuckerberg San Francisco
Priscilla Chan and Mark Zuckerberg San Francisco General Hospital and Trauma Center
General Hospital and Trauma Center, San Francisco, California
San Francisco, California
Debra Keller, MD, MPH
Jessica E. Hawkins, MSE Assistant Professor, Department of Medicine,
Research Associate, Children’s Hospital of Philadelphia and the School of Medicine, University of California San Francisco,
University of Pennsylvania School of Medicine, Philadelphia , Priscilla Chan and Mark Zuckerberg San Francisco
Pennsylvania General Hospital and Trauma Center
San Francisco, California
Jennifer E. Hettema, PhD
Toby Keys, MA, MPH
Associate Research Professor, Department of Family and
Community Medicine, Education Specialist, RUOP
University of New Mexico, Medical Student Education Section
Albuquerque, New Mexico Department of Family Medicine
School of Medicine
University of Wa shington
Jonas Z. Hines, MD Seattle, Wa shington
Staff Physician, Tom Waddell Health Center,
San Francisco Department of Public Health, Leigh Kimberg, MD
San Francisco, California
Professor, Department of Medicine,
School of Medicine, University of California San Francisco,
Claire Horton, MD, MPH Priscilla Chan and Mark Zuckerberg San Francisco
Associate Professor, Department of Medicine General Hospital and Trauma Center
School of Medicine, Division of General Internal Medicine San Francisco, California
(DGIM)
University of California San Francisco Margot Kushel, MD
Priscilla Chan and Mark Zuckerberg San Francisco Professor, Department of Medicine,
General Hospital and Trauma Center School of Medicine, University of California San Francisco,
San Francisco, California Priscilla Chan and Mark Zuckerberg San Francisco
General Hospital and Trauma Center
Margaret Hutchison, MSN, CNM San Francisco, California
Professor, Department of Obstetrics, Gynecology and
Reproductive Sciences, C. Seth Landefeld, MD
School of Medicine, University of California San Francisco, Chair, Department of Medicine, Spencer Chair in Medical
Priscilla Chan and Mark Zuckerberg San Francisco Science Leadership,
General Hospital and Trauma Center University of Alabama at Birmingham, Birmingham, Alabama
San Francisco, California
Daniel S. Lessler, MD, MHA
Lisa I. Iezzoni, MD, MSc
Chief Medical Officer, Wa shington State Health Care Authority,
Professor of Medicine, Harvard Medical School; Director, Professor, Medicine and Health Services,
Mongan Institute for Health Policy, Ma ssachusetts University of Wa shington, Olympia , Wa shington
General Hospital, Boston, Ma ssachusetts
Bernard Lo, MD
Elizabeth A. Jacobs, MD, MPP
President and CEO, The Greenwall Foundation, New York,
Professor of Medicine and Population Health, University of New York;
Wisconsin School of Medicine and Public Health; Associate Vice Professor of Medicine Emeritus;
Chair for Health Services Research, Department of Medicine and Director Emeritus, Program in Medical Ethics,
Health Innovation Program, University of Wisconsin-Madison, University of California ,
Madison, Wisconsin San Francisco, California
 Contributors x iii

Courtney R. Lyles, PhD Susana Morales, MD

Assistant Professor of Medicine, Division of General Internal Associate Professor of Medicine,
Medicine, Department of Medicine,
School of Medicine, University of California San Francisco Weill Medical College of Cornell University,
Priscilla Chan and Mark Zuckerberg San Francisco New York, New York
General Hospital and Trauma Center,
San Francisco, California
Christopher Neumann, PhD

Sarah Macfarlane, PhD, MSc Assistant Professor,

Department of Family and Community Medicine,
Professor, Department of Epidemiology and Biostatistics, School of Medicine, University of New Mexico,
School of Medicine and Global Health Sciences, University of Albuquerque, New Mexico
California , San Francisco, San Francisco, California
Carolyn Payne, MD
Megan Mahoney, MD
Resident, Department Obstetrics and Gynecology, Tufts Medical
Associate Chief of Primary Care, Associate Professor, Division of Center, Boston, Ma ssachusetts
General Medical Disciplines, Department of Medicine, Stanford
University, Palo Alto, California
John D. Piette, PhD

Rishi Manchanda, MD, MPH Senior Research Career Scientist, VA Ann Arbor Center for
Clinical Management Research; Professor of Health Behavior
President, HealthBegins, Los Angeles, California and Health Education, University of Michigan School of Public
Health; Professor of Internal Medicine, University of Michigan
Christina Mangurian, MD Medical School; Director University of Michigan Center for
Managing Chronic Disea se, Ann Arbor, Michigan
Associate Professor, Department of Psychiatry,
School of Medicine, University of California San Francisco,
Priscilla Chan and Mark Zuckerberg San Francisco Michael B. Potter, MD
General Hospital and Trauma Center
Professor, Department of Family and Community Medicine,
San Francisco, California
School of Medicine, University of California San Francisco,
Priscilla Chan and Mark Zuckerberg San Francisco
Brigid McCaw, MD, MPH, MS General Hospital and Trauma Center
Medical Director, Family Violence Prevention Program, San Francisco, California
Kaiser Permanente, Oakland, California
Francisco Ramos-Gomez, DDS, MS, MPH
Steven Meltzer, PA Professor, Section of Pediatric Dentistry,
Faculty, MEDEX Northwest Physician Assistant Program, School of Dentistry, University of California Los Angeles,
Department of Family Medicine, University of Wa shington Los Angeles, California
School of Medicine, Seattle, Wa shington
Neda Ratanawongsa, MD, MPH
Pooja Mittal, DO Associate Professor of Medicine, Division of General Internal
Associate Professor, Department of Family and Community Medicine,
Medicine, School of Medicine, University of California San Francisco
School of Medicine, University of California San Francisco, Priscilla Chan and Mark Zuckerberg San Francisco
Priscilla Chan and Mark Zuckerberg San Francisco General Hospital and Trauma Center
General Hospital and Trauma Center San Francisco, California
San Francisco, California
Patricia A. Robertson, MD
Erica Monasterio, MN, FNP-BC
Professor and Director of Medical Student Education
Professor, Director, Family Nurse Practitioner Program, Family Division of Maternal-Fetal Medicine
Health Care Nursing; Division of Adolescent and Young Adult Department of Obstetrics, Gynecology and
Medicine, Reproductive Sciences,
School of Nursing, University of California San Francisco, School of Medicine,
San Francisco, California University of California , San Francisco
x iv Contributors

Marisa Rogers, MD, MPH Dean Schillinger, MD

Associate Professor of Medicine, Professor, Department of Medicine
Perelman School of Medicine, University of Pennsylvania , Chief of Division of General Internal Medicine (DGIM)
Philadelphia , Pennsylvania School of Medicine
University of California , San Francisco
Priscilla Chan and Mark Zuckerberg San Francisco
Sara Rosenbaum, JD General Hospital and Trauma Center
Harold and Jane Hirsh Professor of Health Law and Policy, San Francisco, California
Department of Health Policy, Milken Institute School of Public
Health, George Wa shington University, Wa shington, DC Michelle Schneidermann, MD
Professor, Department of Medicine,
Anne Rosenthal, MD School of Medicine,
University of California , San Francisco,
Associate Medical Director, Ma xine Hall Health Center
Priscilla Chan and Mark Zuckerberg San Francisco
San Francisco Department of Public Health,
General Hospital and Trauma Center, San Francisco, California
Assistant Professor, Department of Medicine,
School of Medicine
University of California San Francisco Naomi Schoenfeld, MS, FNP-BC
San Francisco, California Nurse Practitioner, Family Health Center,
Priscilla Chan and Mark Zuckerberg San Francisco General
George William Saba, PhD Hospital and Trauma Center; Assistant Clinical Professor,
Family Nurse Practitioner Program, Family Health Care
Professor, Department of Family Community Medicine, Nursing,
School of Medicine, University of California San Francisco University of California San Francisco,
Priscilla Chan and Mark Zuckerberg San Francisco San Francisco, California
General Hospital and Trauma Center
San Francisco, California Tracy Schrider, LCSW, ACM
Administrative Supervisor of Social Work,
Bradley W. Samuel, PhD Sutter Health-Alta Bates Summit Medical Center,
Associate Professor; Director, Behavioral Health Education; Berkeley, California
Clinical Director, Behavioral Health Integration in Primary
Care, Department of Family and Community Medicine, Steven A. Schroeder, MD
University of New Mexico School of Medicine, Albuquerque,
Professor, Department of Medicine,
New Mexico
School of Medicine,
University of California San Francisco,
Megan Sandel, MD, MPH San Francisco, California

Associate Professor of Pediatrics and Public Health,

Boston University Schools of Medicine and Public Health, Hilary K. Seligman, MD, MAS
Boston, Ma ssachusetts Associate Professor, Departments of Medicine
and Epidemiology and Biostatistics,
School of Medicine,
Urmimala Sarkar, MD, MPH
University of California San Francisco,
Associate Professor, Department of Medicine, Priscilla Chan and Mark Zuckerberg San Francisco
School of Medicine, Division of General Internal Medicine General Hospital and Trauma Center
(DGIM) San Francisco, California
University of California San Francisco
Priscilla Chan and Mark Zuckerberg San Francisco J. Ryan Shackelford, MD
General Hospital and Trauma Center
San Francisco, California Assistant Professor
Department of Psychiatry
Medical Director of Behavioral Health Homes
Ellen M. Scarr, PhD, FNP-BC Community Behavioral Health Services and
Professor, Family Health Care Nursing, Community Oriented Primary Care
School of Nursing, University of California San Francisco, San Francisco Public Health Department
San Francisco, California San Francisco, California
 Contributors xv

William B. Shore, MD Cam-Tu Tran, MD, MS

Professor of Clinical Family and Community Medicine, Associate Professor,
University of California , San Francisco, School of Medicine Department of Pediatrics,
University of California , San Francisco School of Medicine, University of California San Francisco,
Priscilla Chan and Mark Zuckerberg San Francisco Priscilla Chan and Mark Zuckerberg San Francisco
General Hospital and Trauma Center General Hospital and Trauma Center
San Francisco, California San Francisco, California

Shane Snowdon, MA Jacqueline P. Tulsky, MD

Harvard Divinity School, Professor, Department of Medicine
Cambridge, Ma ssachusetts School of Medicine
University of California , San Francisco
Priscilla Chan and Mark Zuckerberg San Francisco
Margaret Stafford, MD General Hospital and Trauma Center
Assistant Professor, Department of Family and Community San Francisco, California
Medicine;
School of Medicine
Maya Vijayaraghavan, MD, MAS
University of California San Francisco
Director of Education, Family Medicine Inpatient Service, Assistant Professor,
Priscilla Chan and Mark Zuckerberg San Francisco Department of Medicine, Division of General Internal Medicine
General Hospital and Trauma Center, (DGIM)
San Francisco, California School of Medicine
University of California San Francisco
Priscilla Chan and Mark Zuckerberg San Francisco
Jody Steinauer, MD, MAS General Hospital and Trauma Center
Professor, Department of Obstetrics, Gynecology and San Francisco, California
Reproductive Sciences,
School of Medicine
Teresa J. Villela, MD
University of California San Francisco,
Priscilla Chan and Mark Zuckerberg San Francisco Professor, Department of Family Community Medicine,
General Hospital and Trauma Center School of Medicine, University of California San Francisco,
San Francisco, California Priscilla Chan and Mark Zuckerberg San Francisco
General Hospital and Trauma Center
San Francisco, California
Jeffrey N. Stoneberg, DO
Medical Director, Palliative Care,
Alexander Y. Walley, MD, MSc
Alta Bates Summit Medical Center,
Oakland, California Assistant Professor of Medicine, Clinical Addiction Research and
Education Unit, Section of General Internal Medicine, Boston
University School of Medicine, Boston, Ma ssachusetts
Stephanie Taché, MD, MPH
Director, Refugee Clinic, Dresden
Emily A. Wang, MD, MAS
Assistant Professor Family and Community Medicine
School of Medicine Associate Professor, Department of Internal Medicine,
University of California , San Francisco Yale University School of Medicine,
Priscilla Chan and Mark Zuckerberg San Francisco New Haven, Connecticut
General Hospital and Trauma Center
San Francisco, California
Margaret Wheeler, MD
Professor, Department of Medicine,
Emily H. Thomas, MD, MS
School of Medicine, University of California San Francisco,
University of California , San Francisco Priscilla Chan and Mark Zuckerberg San Francisco
Resident in Internal Medicine General Hospital and Trauma Center
SFGH Primary Care San Francisco, California
San Francisco, California
xvi Contributors

Ellen-Marie Whelan, PhD, NP Sharon L. Youmans, PharmD, MPH

Senior Advisor, CMS Center for Medicare and Medicaid Professor of Clinical Pharmacy and Vice Dean,
Innovation, Baltimore, Maryland University of California San Francisco School of Pharmacy,
San Francisco, California
Naomi Wortis, MD
Barry Zevin, MD
Professor, Department of Family and Community Medicine,
School of Medicine, University of California San Francisco, Clinical Lead, Transgender Health Services;
San Francisco, California Medical Director, Homeless Outreach Team,
Priscilla Chan and Mark Zuckerberg San Francisco San Francisco Department of Public Health,
General Hospital and Trauma Center San Francisco, California
San Francisco, California
Pre face

In the near decade since we published the irst edition o worldwide and believe that the concepts and approaches
this book, research has irmly established that populations are relevant to medical practice globally.
o lower socioeconomic status and rom minority racial he purpose o this book is to o er the theoretical
and ethnic backgrounds have worse health and o ten background and practical knowledge required to teach
receive a lower standard o health care. Worse health out- clinicians to care or vulnerable, underserved patients
comes attributed to inequity in distribution o resources, both at the individual and system levels. In this book, we
initially termed disparities in health and health care, are aim to illuminate the complexities o caring or vulnera-
now more aptly and pointedly re erred to as inequities in ble, underserved patients. We provide both an appreci-
health and health care. hese inequities are attributed to ation o the need to address inequities at multiple levels
broad social orces that shape the way we live and how and practical suggestions or how to improve the care
medicine is practiced. With this perspective, a person’s o vulnerable populations. We aim to “enable” health-
and a community’s health and the health care they receive care workers, students, and other interested parties to
are measures o social justice. contribute to the solution. We ocus on issues o patient
As clinicians, there is perhaps no more distressing care that are common among underserved patients and
medical research than that which suggests that health- suggest ways to use our materials as teaching tools or
care workers and the health-care system contribute to health pro essions trainees in both didactic and clinical
inequities in health or vulnerable populations. Studies settings.
reveal that health-care workers continue to eel ill pre- Our book is intended as a basis or teaching the core
pared when caring or vulnerable patients, especially principles and skills required to care or our most com-
those who are chronically ill, the elderly, addicted, men- plex patients—the vulnerable and underserved—where
tally ill, victims o violence, or rom minority or disadvan- our clinical skills must be the most astute. Our text is
taged backgrounds. Hence, health-care workers may be appropriate or students, residents and practitioners
the third actor in a “triple jeopardy” vulnerable patients (medical students, nurses, pharmacists, physician’s assis-
ace when it comes to health care: not only are these tants, public health, and other health-care practitioners)
patients more likely to be ill and to have di iculty access- both in clinical, community, or social medicine classes
ing care, but when they do, the care they receive is more and in practical experiences, including, but not limited
likely to be suboptimal. Fortunately, training health-care to, primary care rotations and clerkships in amily med-
workers to care or vulnerable patients makes a di erence. icine, pediatrics, internal medicine, women’s medicine,
With training, they are more willing to work with these and psychiatry. As teaching hospitals are the major pro-
populations and provide better care. viders o care to uninsured, poor, and minority patients in
We hope the second edition o our book will be part the United States, the book is also intended as a resource
o an ongoing process o improving our pro essions’ abil- or teachers and trainees who practice in these settings
ity to discharge its obligation to enhance social justice by as well as public health-care settings internationally. Post-
both delivering comprehensive care or all patients and graduate trainees (e.g., residents and ellows) rom all dis-
challenging the policies that undermine health or under- ciplines could use this text or didactics in behavioral and
privileged patients and health-care access and delivery. clinical medicine, and quality improvement. Finally, it can
Although grounded in health care as it is practiced in also serve as a rapid, yet comprehensive re erence or all
the United States, we draw rom evidence and practices practitioners.

x v ii
x v iii Pre ace

he book is organized into three sections: Principles, o care delivery to improve the e ectiveness o medical
Practice, and Populations. Chapters in each section dis- care, such as the patient-centered medical home, group
cuss ways in which both the individual practitioner medical visits, and use o interactive health technologies;
and the health-care system may be more responsive to as well as quality improvement and case management
patients with these characteristics to assure they receive programs. he third section, Popula tions, examines par-
accessible, high-quality care, thereby reducing the inequi- ticular conditions or social circumstances that can lead
ties in health care that are both causes and consequences to worse care. Chapters consider approaches to patients
o vulnerability. We present clinical approaches to many with histories o trauma, mental illness, intimate partner
issues that complicate caring or socially vulnerable violence, and addiction, or example. Care o patients with
patients. Many chapters eature both Key Concepts and limited English pro iciency, history o incarceration, gay,
Common Pitfalls, and end with a Core Competency high- lesbian and transgender patients, children, adolescents,
lighting important concepts and skills or quick and easy and the elderly are subjects o others. In addition, this
re erencing. section addresses common situations that uniquely com-
Putting together a book o this scope and magnitude plicate the care o vulnerable populations such as envi-
was no easy task and involved making certain decisions ronmental and occupational illnesses; the care o socially
that not all readers may agree with. For example, while complicated hospitalized patients; end-o -li e health care;
trying to keep the length o the book as manageable as chronic pain management; dental health; the care o
possible, we were orced to exclude some relevant topics patients with HIV/AIDS; and patients with disabilities.
and decided to allow some overlap o content in those We end with a chapter that addresses the prevention o
areas that are most critical. In addition, we welcomed di - practitioner burnout.
erences o opinion among authors, provided the issues We are deeply appreciative to the authors or their
were clearly stated and the reasons or the author’s opin- outstanding contributions to both editions o the book.
ion documented. Although the authors o some chapters have changed, we
he irst section, entitled Principles, lays out the theo- wish to acknowledge the in luence and contribution o
retical groundwork o the book. opics discussed include those who laid the oundation in the original chapters. We
overview o the concepts o medical vulnerability and would also like to acknowledge the support and patience
inequities in health and health care; inancing and organi- o the sta at McGraw-Hill. We especially wish to rec-
zation o health care or vulnerable populations; laws and ognize the e orts o James Shanahan or believing in the
regulations governing the care o medically underserved project since its inception and to Amanda Fielding, Kim
populations in the United States; and ethical dilemmas Davis, Laura Libretti, and Kritika Kaushik or bringing it
that arise in the clinical care o medically underserved to ruition. Finally, we are orever grate ul to our patients
populations. We also present chapters on engaging com- or allowing us to participate in their care, our students
munities, on a global health-care perspective and pro- or inspiring us to do better, and our amilies or their
moting physician advocacy. he second section, Pra ctice, generous support.
considers overarching themes and skills necessary to care almadge E. King, Jr., MD
or patients. In particular, this section concentrates on Margaret B. Wheeler, MS, MD
population medicine and systems approaches to improv- Andrew B. Bindman, MD
ing care to vulnerable patients. opics discussed include Alicia Fernandez, MD
the importance o building a therapeutic alliance and Kevin Grumbach, MD
assessing or vulnerability; supporting health behavior Dean Schillinger, MD
change and adherence; principles o e ective communi- eresa J. Villela, MD
cation when cultural or literacy barriers may exist; models
PART 1
Principle s
CHAP TERS
1 Vu ln e ra b le Po p u la tio n s , He a lth Dis p a ritie s , a n d He a lth
Eq u ity: An Ove rvie w
2 He a lth -Ca re Dis p a ritie s : An Ove rvie w
3 Fin a n cin g a n d Orga n iza tio n o f He a lth Ca re fo r Vu ln e ra b le
Po p u la tio n s
4 Le ga l Is s u e s in th e Ca re o f Un d e rs e rve d Po p u la tio n s
5 Prin cip le s in th e Eth ica l Ca re o f Un d e rs e rve d Pa tie n ts
6 Co m m u n ity En ga g e m e n t a n d Pa rtn e rs h ip
7 A Glo b a l Pe rs p e ctive o n th e Ca re o f Me d ica lly Vu ln e ra b le
a n d Un d e rs e rve d Po p u la tio n s
8 Ad vo ca cy
Ch a p te r 1

Vulne rable Po pulatio ns , He alth

Dis paritie s , and He alth Equity:
An Ove rvie w
Kevin Grum bach, MD, Paula Brave m an, MD, MPH, Nancy Adle r, PhD, and
Andrew B. Bindm an, MD

Objectives
• Define the terms vulnerable populations, health disparities, and health equity.
• Distinguish among differences in health, health disparities, and health-care disparities.
• Understand the relationship between social vulnerability and health disparities, and the
pathways mediating this association.
• Recognize the ethical and human rights principles underlying efforts to achieve health
equity
• Identify actions health professionals may take to change the social conditions that create
vulnerability and produce health disparities.

IN TRO D UC TIO N their skills to respond effectively to the health-care

needs of vulnerable patients but also to take action to
“Vulnerable” derives from the Latin word for wounded.
change the fundamental social conditions that produce
Populations can be vulnerable for a variety of reasons. In
vulnerability.
this chapter, we focus on populations that are wounded
by social forces that place them at a disadvantage with
respect to their health. Vulnerability is visible in the
WHAT A RE HEA LTH A N D HEA LTH-CA RE
variation across social groups in levels of resources and
D IS PA RITIES ?
social influence and acceptance, as well as in the inci-
dence, prevalence, severity, and consequences of health Webster’s dictionary defines disparity as a difference.
conditions. “Difference” sounds like a neutral concept. It may seem
This chapter provides an over view of the concept logical that different people have different states of health,
of vulnerability. It begins by introducing the notion of requiring different kinds and quantities of care. For
health disparities, distinguishing it from simple differ- example, elderly people are expected to be less healthy
ences in health, and defining the closely related concept than young adults. People who ski are more likely to suffer
of health equity. It describes evidence of health dispari- leg fractures than people who do not.
ties, particularly by socioeconomic status (SES) and race/ Concern for health disparities is not about all differ-
ethnicity. It then discusses conceptual models for under- ences in health, but rather about a subset of differences
standing the pathways between social vulnerability and that are avoidable and suggest social injustice. Although
poor health status. It concludes by suggesting that health few readers of this book probably were moved to righ-
professionals have a responsibility not only to develop teous indignation by the health differences cited in the

2
 Chapter 1 / Vu ln er able Pop u lat ion s, H ealt h Disp ar it ies, an d H ealt h Eq u it y: An O ver vie w 3

example of skiers and more frequent broken bones, the RO LE O F S O C IO ECO N O M IC C LAS S
following observations are likely to prompt qualitatively A N D RAC E/ETHN IC ITY IN HEA LTH
different reactions: A baby born to an African-American D IS PA RITIES
mother in the United States is more than twice as likely
Profound and pervasive disparities in health associated
to die before reaching her or his first birthday as is a baby
with a range of socioeconomic factors such as income or
born to a white mother.1 A World Bank study of 56 coun-
wealth, education, and occupation have repeatedly been
tries revealed that, overall and within virtually every
documented in the United States and globally.2,7-9 Despite
country, infant and child mortality were highest among
ongoing debates about whether causation has been defini-
the poorest 20% of the population and lowest among the
tively established, considerable evidence has accumulated
best-off 20% of the population; the disparities were large
demonstrating, at a minimum, the biological plausibility
in absolute as well as relative terms.2
of those associations.10,11 Similarly, virtually wherever data
on health according to race or ethnic group have been
HEALTH DIS PARITIES measured, racial or ethnic disparities in health also have
often been observed; these disparities sometimes, but not
“Health disparities” is a shorthand term denoting a spe- always, have disappeared or been markedly reduced once
cific kind of health difference between more and less priv- socioeconomic and other contextual differences have
ileged social groups. It refers to differences that adversely been accounted for.12-14
affect disadvantaged groups that are systematic and
persistent, not random or occasional, and that are at least
theoretically amenable to social intervention. The social S OCIOECONOMIC STATUS
groups being compared are differentiated by their under-
Social class shows a strong association with health and
lying social position, that is, by their relative position in
longevity. Higher SES provides individuals with more
social hierarchies defined by wealth, power, and/or pres-
material, psychological, and social resources, which can
tige; this includes socioeconomic, racial/ethnic, gender,
benefit their health. There is no standardized method for
and age groups and groups defined by disability, sexual
defining or measuring social class in the clinical setting,
orientation or identity, or other characteristics reflecting
and this information is not routinely collected as a part of
social privilege or acceptance.3-5
health-care encounters. Some of the typical dimensions of
social class used in research studies include occupation,
HEALTH-CARE DIS PARITIES income, and education level, which are all components of
what is generally referred to as socioeconomic status.
Disparities in health care, as opposed to disparities in Some of the most compelling evidence about the asso-
health, refer to systematic differences in health care ciation between SES and health comes from the White-
received by people based on these same social character- hall study in the United Kingdom. This research on
istics. Although disparities in health care account for only British civil servants demonstrated a linear association of
a relatively small proportion of disparities in health, they higher occupational grade with lower 10-year mortality.15
are of particular importance to health-care providers and This was a striking finding because significant differences
are discussed in detail in the next chapter. in mortality occurred in a population in which all par-
ticipants were employed and had health-care coverage.
Despite the relative homogeneity of the group, those in
HEALTH EQUITY higher occupational grades had significantly lower rates
For individuals concerned about vulnerable and under- of a number of diseases as well as lower mortality. These
served populations, one overarching objective is eliminat- differences remained 25 years later, even after some of
ing health disparities. A slightly different way of framing the civil servants had retired from their jobs.16 A similar
this aspiration is to state that the goal is to achieve health SES and health gradient has been observed in the United
equity. This frames the objective as a positive one (achiev- States. A 2010 study using national data observed step-
ing equity) rather than a negative one (eliminating dispar- wise incremental gradients of health improving as either
ities). This approach mirrors defining health as a positive income or educational level rose, for scores of indicators
state of well-being and not just the absence of disease. across the life course.8
Health equity may be understood as a desired state of
social justice in the domain of health, and health dispar-
INCOME AND HEALTH
ities as the metric used to measure progress toward this
state. A reduction in health disparities is evidence of mak- Analyses of the SES gradient generally reveal a sharp drop
ing progress toward greater health equity.6 in mortality as income increases from the most extreme
4 Part 1 / Principles

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Le s s tha n High-s chool S ome colle ge Colle ge gra dua te
46 high s chool gra dua te
Educa tiona l a tta inme nt
44
<100% FP L 100%-199% FP L 200%-399% FP L ≥400% FP L Fig u r e 1-2 . Educational attainm e nt and life expe ctancy at
Fa mily income a s pe rce nta ge of fe de ra l pove rty leve l (FP L) age 25 in the United State s . This figure de scribe s the numbe r
of ye ars that adults in diffe re nt e ducation groups can expe ct
Fig u r e 1-1. Family income and life expectancy at age 25 in the
to live beyond age 25. For example , a 25-ye ar-old man w ith a
United States. This figure describes the number of years that
high school diplom a can expe ct to live 51.4 additional ye ars
adults in different income groups can expect to live beyond age
and re ach an age of 76.4 ye ars . (Source : CDC/NCHS, National
25. For example, a 25-year-old man with a family income below
Health Inte rview Survey Linked Mortality File , 2006. National
100% of the federal poverty level can expect to live 49.2 additional
Ce nte r for He alth Statistics. He alth, Unite d State s 2011: With
years and reach an age of 74.2 years. (Source: CDC/NCHS,
Spe cial Feature on Socioe conom ic Status and He alth. Hyattsville,
National Health Interview Survey Linked Mortality File, 2006.
MD: 2012. http://w w w.cdc.gov/nchs /data/hus/2011/fig32.pdf.)
National Center for Health Statistics. Health, United States 2011:
With Special Feature on Socioeconomic Status and Health. Hyatts-
ville, MD: 2012. http://www.cdc.gov/nchs/data/hus/2011/fig32.pdf.)
as income increases (albeit with a sharper drop in
the lower portion of the distribution), the association
categories of poverty toward more moderate poverty, and
between mortality and education is more discontinuous.
a continued but more gradual drop in mortality as incomes
For all-cause mortality and each of the specific causes,
rises above this moderate poverty level. The National Lon-
the death rates are lower for those with more educa-
gitudinal Mortality Survey in the United States showed a
tion (Figure 1-2). To the extent that education provides
difference of more than 6 years of life expectancy at age 25,
information, knowledge, and skills that improve health,
between those who were poor and those with incomes
each additional year of education should contribute
more than four times the poverty level; there was a 2-year
somewhat equally to improved health. However, educa-
difference in life expectancy at age 25 between those with
tional attainment also serves a credentialing function.
intermediate-level incomes (200– 399% of poverty) and
As a result, there is a greater benefit of achieving years
the higher-income group (Figure 1-1).8
of schooling that result in a degree or credential than of
Above and beyond one’s own economic status, there
additional years that do not. Thus, the benefit of com-
is some evidence that the distribution of income across
pleting the 12th year of schooling, which results in a high
a population makes a difference. Although still being
school degree, is greater than the benefit of completing
debated, income inequality itself may be bad for people’s
any other single year of high school (referred to as the
health, irrespective of the average overall standard of liv-
“sheepskin” effect).
ing in a society. As discussed in Chapter 7, cross-national
The data linking education and health can more clearly
comparisons indicate that nations with less income
be interpreted as a causal effect of education and health
inequality have better overall health indicators than
than is the case for income and health. While poor health
nations at a comparable level of economic development
can reduce one’s income,18 education occurs earlier in life
with more unequal income distribution.17
than do most serious diseases, and this temporal ordering
Wealth is another measure of economic status. Wealth
provides a strong rationale for attributing the association
includes not just income, but also the value of assets such
to the impact of education on health.
as home ownership, real estate, and investments—assets
Data in the United States on SES and health have been
that often accumulate among families over generations.
limited. While public health monitoring and epidemio-
Wealth tends to have an even more inequitable distribu-
logic surveys frequently collect information on race and
tion across a population than does income.
ethnicity, they less often include information on income
or education. Until recently, death certificates had only
EDUCATION AND HEALTH
data on race and ethnicity, but now include information
In contrast to the relationship between income and on education but not occupation, income, wealth, or
health, which demonstrates a continued drop in mortality other SES variables.
 Chapter 1 / Vu ln er able Pop u lat ion s, H ealt h Disp ar it ies, an d H ealt h Eq u it y: An O ver vie w 5

RACE/ ETHNICITY distinctions between the concept of race and ethnicity are
an oversimplification of this socially defined construct,
Race and ethnicity often are combined and referred to as
and we use the term “race– ethnicity” to communicate a
one concept. Nevertheless, the concept of race as com-
more holistic notion of this concept.
monly used tends to evoke differences in skin color and
Disparities by race– ethnicity are present in the United
other superficial secondary characteristics, whereas eth-
States for such diverse health indicators as infant mor-
nicity incorporates the concept of culture.19
tality, cancer mortality, coronary heart disease mortality,
The health implications of classification of both racial
and the prevalence of diabetes, HIV infection, or stroke
and ethnic groups derive primarily from the social con-
(Table 1-1). Two clear observations can be made about
struction and impact of being labeled as belonging to one
these health outcomes categorized by race and ethnicity.
or another group. Apart from a small number of genes
First, African Americans experience the greatest mor-
that code for skin color and other superficial secondary
bidity and mortality on every reported indicator, and the
characteristics, and a few genes that are linked to geo-
gap often is substantial. For example, African Americans
graphic origin which confer risk for specific diseases,
experience 12.7 deaths for every 1000 live births, com-
there is little biologic basis for health disparities among
pared with Asian or Pacific Islanders, who experience 4.5
racial and ethnic groups. Advances in genomics have
deaths. Second, no other group shows consistently poor
exposed the concept of race as predominantly a social
health outcomes across all indicators. Whites show poorer
construct, rooted in historical biases and social stratifica-
outcomes than groups other than African Americans on
tion based on ancestry and superficial phenotype rather
many of the reported health indicators (e.g., overall can-
than emanating from fundamental genetic differences
cer mortality). American Indians and Alaska natives have
among populations perceived to be of different “races.”
the second highest rates of infant mortality, and Hispanics
There is no gene or set of genes that are exclusive to one
or Latinos have the second highest prevalence of diabe-
race and that can be used to define those belonging to a
tes. Asian Americans and Pacific Islanders show the most
race. Stated another way, one cannot look at a person’s
favorable profile.
DNA and tell definitively that she or he is Asian, African
One limitation of these conclusions is that they are
American, Latino, or white. The genetic variation among
based on large groupings by race– ethnicity. These broad
people within a racial and ethnic group is much greater
categories may obscure substantial variation in health
than the variation across groups.20
within some of the groups. Members of the same major
Despite the lack of definitive genetic determinants,
racial– ethnic group from different countries and areas of
race and ethnicity have important influences on health.
origin have different degrees of disadvantage and health
Based on historical conventions, US federal agencies use a
risk. For example, among Latinos and Hispanics in the
two-item approach to classification. The first item is con-
United States, the infant mortality rate is 4.9 among
sidered to represent race, and includes five major groups:
Cubans and 7.3 among Puerto Ricans. The importance
African American or black, American Indian or Alaska
of looking at subgroups also may differ by disease. For
native, Asian, native Hawaiian or other Pacific Islander,
example, Asian Indians have the lowest rates of all-cause
and white. The second item is considered to measure eth-
mortality, yet they have relatively high rates of coronary
nicity, and consists solely of a dichotomous categorization
heart disease compared with other Asian groups.21
of Hispanic or non-Hispanic. In our view, such categorical

Ta b le 1-1. He a lth Dis p a ritie s b y Co n d itio n a n d Ra ce –Eth n icity

Race/Ethnicity

Black/African Hispanic/ Asian and Pacific American Indian

Health Condition and Specific Example White American Latino Islander and Alaska Native

Infant mortality: rate per 1000 live births 5.5 12.7 5.6 4.5 8.4
Cancer mortality: rate per 100,000 173 206 120 108 158
Lung cancer mortality: rate per 100,000 49 52 21 25 40
Female breast cancer mortality: rate per 100,000 22 31 15 11 15
Coronary heart disease: mortality rate per 100,000 118 141 87 67 92
Stroke: mortality rate per 100,000 38 56 30 32 30
Homicides, per 100,000 2.6 19.9 6.6 2.2 9.0
HIV infection: prevalence per 100,000 adults 17 128 50 15 32
Diabetes: prevalence per 100 adults 6.8 11.3 11.5 10.2 DSU

DSU, data are statistically unreliable.

Source: CDC Health Disparities and Inequalities Report, United States, 2013. MMWR 2013;62(Suppl), No. 3; National Cancer Institute, SEER Cancer Statistics Review
1975– 2011.