There has been a lot of use of the expression “vulnerable populations” with respect to health lately. Politicians of every stripe use this expression while advocating for their particular position on health care funding. It’s an effective rhetorical tool: after all, who is not in favor of helping the vulnerable among us? Health resources are scarce, and to the extent that we are able to redistribute those resources, we would like to favor the populations that are in the most need. The problem, of course, is that the expression ”vulnerable” is vague enough to mean whatever the speaker wants it to mean. Some clarification is in order. What, then, is a “vulnerable population”?
Location, location, location
In a geographical community, the entire population is not necessarily always vulnerable to adverse health outcomes. However, there are some geographical communities, such as prisons and Native American reservations, in which all individuals are indeed vulnerable, whether the risk be physical violence or exposure to infectious disease. Likewise, as a result of war or natural disaster, entire geographical populations may become vulnerable to disease or death.
Prisoners and Native Americans are generally not the groups politicians refer to when they speak of vulnerable populations, even though these groups are uniquely vulnerable. Rather, they are referring to individuals among us in the general population, who are classified as belonging to particular vulnerable populations based on age or gender, or because of a particular disease or disability.
Children are generally referred to as a vulnerable population with respect to their health because of their relative inability to advocate for their own interests and to protect themselves from harm. The World Health Organization identifies children as being particularly vulnerable to poor health outcomes, especially in the case of natural disasters or other calamities1. For this reason, some states, including Massachusetts, provide basic health insurance coverage to children regardless of their eligibility for Medicaid.
Likewise, senior citizens are considered a vulnerable population, even if an individual elderly person is physically able to care for herself and is in full possession of her mental capacity. This is because in the event of a disaster, seniors, like children, are particularly likely to suffer disproportionately compared with their younger neighbors. In the UK, the law mandates that communities assess the needs of the elderly and make reasonable accommodation of those needs.
The chronically ill
People with chronic diseases are, by definition, at-risk for poor health outcomes. The reason they are grouped together as vulnerable populations is simply that sick people consume more health care dollars than do well people. Recognizing this increased risk, Congress regularly mandates expenditures to pay for the needs of the chronically ill, as they did with passage of the 21st Century Cures Act in 2016.
American non-English speakers
When an American non-English speaker becomes ill, they immediately become vulnerable to adverse health outcomes, even if they have health insurance and enjoy access to excellent medical facilities. When one is ill, it is particularly important to be able to communicate with first responders and medical personnel. Despite advances in translation technology, the language barrier introduces a substantial amount of vulnerability to poor health outcomes.
Vulnerable or at-risk?
Often, we hear children and the elderly referred to as “at-risk” populations. Is “at-risk” the same as “vulnerable,” and if not, what are the differences between the two concepts?
According to the Organization for Economic Co-operation and Development, the definition of risk depends entirely on exposure. If (and only if) one is exposed to a threat, one is at-risk of experiencing the outcome of that threat. For example, all living humans are at risk of dying, but only legally married people are at risk of divorce. According to the World Health Organization, risk is defined as “any attribute, characteristic or exposure of an individual that increases the likelihood of developing a disease or injury”2. For example, individuals infected with HIV are at risk for certain opportunistic infections by virtue of their compromised immune systems.
The line between “at risk” and “vulnerable” can be fuzzy, particularly as there are no objective means of defining when some individual passes from being at normal-risk to being at high-risk for a poor health outcome.
General vs. specific
The difference between “vulnerable” and “at-risk” populations comes down to the difference between condition versus status. Vulnerability refers to one’s general condition or state, such as age, gender (or incarceration status). For example, seniors are vulnerable by virtue of their relatively decreased physical capacity. “Risk” refers to specific causes to which one is exposed. For example, people who live in glass houses are exposed to the risk of stone throwers.
Whether we choose to categorize people into vulnerable or at-risk, it is important that we consider the wishes of the individual. Our British cousins are much better at this than we are. It is important that resources be made available to the members of our society who may need them, but no one should be forced to accept “help” when help is not sought.