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Donald A. Barr: Health Disparities in the United States

Cover Donald A. Barr: Health Disparities in the United States. The Johns Hopkins University Press (Baltimore, Maryland 21218-4363) 2014. 2. Auflage. 328 Seiten. ISBN 978-1-4214-1475-1. 52,75 EUR.
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Nowhere in the world has the emphasis on improving health through advancing the technology of health care been more evident than in the United States. The proportion of the U.S. Economy that goes for providing health care rose from 10 percent in 1987 to 18 percent in 2011. This heavy investment in new medications, new facilities, and the new technology of advanced procedures underscores the faith of the American public in the power of health care to improve health status. However, using two common measures of population health, the American population has worse health status than the population in any of the other developed countries. The mean life expectancy in the United States is two to four years less than in other developed countries. The infant mortality was in 2010 in the United States higher than in 30 of the 34 countries of the OECD. It was only better than in Chile, Turkey and Mexico. What are the reasons for this paradox? Perhaps something other than health care drives the health of a community or a society. In the United States, like in other countries, persist wide health disparities between different social groups, and more Americans suffer from poor health than in other developed countries. The book explores how socioeconomic status, race and ethnicity interact with socioeconomic inequality to create and perpetuate these health disparities. It examines the significance of this gulf for the medical community, cultural subsets, and society at large, and analyzes the complex web of social forces that influences health outcomes.


Donald A. Barr, MD, PhD is a professor of pediatrics and education at Stanford University.

Outline and Content

Chapter 1: Introduction to the Social Roots of Health Disparities This chapter offers an introduction to the concept of health disparities, emphasizing that the United States has lower levels of life expectancy and higher rates of infant mortality than nearly all other developed countries, despite all the money Americans spend on health care. Rather than being a result of health care expenditures, disparities in health status appear instead to be a reflection of social and economic inequality. Additionally, we will see that the association between social inequality and health status is a continuous one, across all levels of income and education.

Chapter 2: What is „Health“? How should we Define it? How Should We Measure It? How healthy one person appears, or feels, relative to another person will depend to a large extent on how health is defined and measured. In general, health has three dimensions: Physical health (medical model), health as functioning at a normal level (sociological model) and health as general feeling of well-being (psychological model). A very prominent measurement instrument for health is the 36-items Short-Form Health Survey (SF-36). It measures physical health with four subscales: Physical functioning, role limitations due to physical problems, bodily pain and general health perceptions. Mental health is measured also with four subscales: Vitality, social functioning, role limitations due to emotional problems and general mental health. In this context, the author refers to the danger of approaching health as an moral imperative. He warns us to avoid what is called the tyranny of health in which those who are unwell are assumed to have misbehaved.

Chapter 3: The relationship between Socioeconomic Status and Health, or, They Call it 'Poor Health' for a Reason The author defines the concept of socioeconomic status (SES) and traces the consistent association, over time and across places, between poverty and poor health. By looking at data gathered by the federal government, we will see evidence of this association for a wide range of conditions.

Chapter 4: Understanding How Low Social Status Leads to Poor Health This chapter extends the exploration of SES to look at the issue of inequality, the multiple forms inequality can take, and the association between inequality and poor health across the SES spectrum. Furthermore, the concept of allostatic load, that means the physiological response to the stress of being in a position of social disadvantage, which over a period of years can result in physiological injury and illness.

Chapter 5: Race, Ethnicity, and Health This chapter attempts to explicate the concepts of race and ethnicity as they have been used in the United States. As early as the mid-1700s, the principal racial categories used today by the U.S. Census Bureau were described by scientists as biological in nature, representing fundamental divisions of the human species, investigate the research looking at racial categorization as biologically derived versus that suggesting it is socially constructed. Additionally, it is looked within racial groups to see how ethnically heterogeneous they are. For example, various ethnic groups within the race defined as „blacks“ actually have strikingly different health status and health outcomes.

Chapter 6: Race/Ethnicity, Socioeconomic Status, and Health: Which is More Important in Affecting Health Status? The data is showing consistently that those in minority racial or ethnic groups are likely to be in a position of lower SES. If the health status of those minorities is consistently lower than those of a comparable population of whites, is it because those with poor health tend to have lower SES, or both? The chapter presents consistent evidence that being in a minority racial or ethnic group can be a form of social disadvantage in and of itself, even after taking into account SES.

Chapter 7: Children's Health Disparities With children of Hispanic and other immigrant parents comprising a rapidly increasing share of the U.S. Population, the demographics of the United States is changing. In parallel with the demographic change has been our growing understanding of and appreciation for the powerful effects social inequality can have on early child development, both psychological and biological. The inequality of poverty and residential racial segregation experienced by many children, in particular black children in low-income families, has been shown to contribute to observed disparities in such conditions as asthma and obesity. Identifying and implementing policies for early intervention in the sources of children's health disparities will be a crucial step toward reducing future disparities when today's children are adults with children of their own.

Chapter 8: All things Being Equal, Does Race/Ethnicity Affect How Physicians Treat Patients? Another type of disparity is the disparity in access to health care. A principal determinant of access to health care in the United States is the availability of health insurance. As is the case with health status, those from lower SES groups in the United States also have worse access to health care, based on this economic fact of life. However, a growing body of research has shown that, even when people have the same level of health insurance and are treated for the same disease by the same physicians and hospitals, those from minority racial or ethnic groups often get worse care – either not receiving care when appropriate or receiving that is of lower quality.

Chapter 9: Why does Race/Ethnicity Affect the Way Physicians Treat Patients? In this chapter, the author presents research an racial or ethnic bias on the part of physicians, distinguishing unconscious bias from the conscious racism that plagued the United States for much of the twentieth century. For a variety of medical conditions, a consistent stream of research has shown that, based largely on unconscious processes, physicians in a number of settings provide a different level of care to blacks or other minorities then they do to whites.

Chapter 10: When, if Ever, Is it Appropriate to Use a Patient's Race/Ethnicity to Guide Medical Decisions? This chapter discusses when, if ever, a physician or other health practitioner is justified in using racial or ethnic categorization in deciding the course of a patient's treatment. The author looks at recent trends toward and potential problems with race-based pharmaceuticals – using one drug for white patients, and a different drug for black patients with the same condition.

Chapter 11: What Should We Do to Reduce Health Disparities? The chapters starts with the caveat that not all disparities need to be eliminated as a matter of public policy. Irrespective of race or ethnicity, women live longer on average than do men. However, racial and ethnic health disparities are of a different type from many gender disparities. The author has chosen not to include an extended discussion of gender disparities, nor other disparities such as those based on age or disability. This does not mean to suggest that these other types of disparities are unimportant. Rather, they exist in a different context and stem from different causes, and they deserve their own examination and policy analysis. The author emphasizes access to medical care as an urgent first step to reducing health disparities, because the about 16 % of uninsured Americans are more likely to die earlier and have a poor health status. 80 % of uninsured families have at least one adult who works on a regular basis throughout the year. Thus, the principal of going without health insurance is not poverty or unemployment. It is the lack of affordable health insurance for working adults and their families. Americans have decided to treat health care as essentially a private consumer good of which the poor and unemployed might be guaranteed a basis package (MEDICAID), but which is otherwise to be distributed more and more on the basis of ability to pay (US-economist Uwe Reinhardt 1986). At the end of his book, the author asks: How far have we come in reducing health disparities in the United States. The answer is discouraging. In 2012, Prof. David R. Williams of Harvard School of Public Health, one of the leading national voices in the efforts to reduce health disparities, published a paper, the title of which carries a poignant message: Miles to Go Before We Sleep: Racial Inequities in Health: „Despite thousands of published studies, our current knowledge is limited with regard to the most effective strategies to reduce health inequities, and there is an urgent need to develop a science base to guide societal interventions“ (page 279).


The results of a large body of scientific studies in countries of the European Union in the last thirty years show overall the same discouraging conclusions like in the United States. Social disparities in health still exist in Europe on a about the same level as thirty years ago. This leads to the question, whether the driving social conditions on health status are to powerful to be reduced by any intervention. If this is true, the only measure to improve the health status for all social groups of a population would be to improve the general living conditions at large, and to reduce social disparities itself.

Target Groups

Researchers, lectures and students of the following disciplines: Public health, epidemiology, health sociology, health economic, and health policy. It is also recommended for physicians and other professionals in the medical field and in social work.


This very fundamental book about health disparities in the United States gives an up to date and comprehensive summary of the current scientific knowledge about this important health topic. It offers potential policy- and physician-based solutions for reducing social inequalities in health in the long run.

Rezension von
Prof. Dr. Uwe Helmert

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Uwe Helmert. Rezension vom 02.06.2015 zu: Donald A. Barr: Health Disparities in the United States. The Johns Hopkins University Press (Baltimore, Maryland 21218-4363) 2014. 2. Auflage. ISBN 978-1-4214-1475-1. In: socialnet Rezensionen, ISSN 2190-9245,, Datum des Zugriffs 06.03.2021.

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