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Should the word \u2018vulnerable\u2019 be used in College documents?
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The College Council received a proposal from the Australasian Faculty of Public Health to remove the term \u2018vulnerable\u2019 from College documents. At the same time, the Chapter of Community Child Health felt that there is still validity in the use of the term. In this article, we examine both sides of the debate and allow members to reach their own conclusions.
Chapter of Community and Child Health \u2013 Vulnerability and medical literature
\nVulnerability has been a concept in medical literature since 1983 when it was introduced by Rose and Killien.1
\nThe concept of vulnerability has evolved over the past 35 years and now vulnerable populations are defined as groups and communities at higher risk of poor health because of the barriers they experience to social, economic, political and environmental resources, as well as limitations due to illness or disability (UK National Collaborating Centre for Determinants of Health). It is well embedded as a concept within Community Child Health and helps to reorientate health systems to protect those most at risk and to reduce health inequity.
\nThe term \u2018vulnerable children\u2019 is widely used because it is a summary term that highlights children who are at risk because of their life circumstances. It incorporates children who have been traumatised by their adverse experiences before or after birth, or who have pathophysiological or neurodevelopmental conditions that make them susceptible to doing poorly. One in five Australian children are developmentally vulnerable from either inbuilt disorders or exposure to external risk factors, such as child abuse or neglect, family violence, mental illness, or trauma related to parental addictions (Goldfeld).
\nWhilst vulnerability is twice as likely in poorer families, other groups are also at risk \u2013 Indigenous children are twice as vulnerable, children living in regional areas are over 50 per cent more vulnerable, and children who have not had access to affordable childcare and preschool are more at risk.
\nThe Chapter of Community Child Health Committee discussed the use of other terms and identified \u2018priority populations\u2019 as a potential option. Although this is a positive term, it has implications for service delivery, which varies across Australia and Aotearoa New Zealand, and may lose some of the implications of risk that the term vulnerable imparts. We do acknowledge that using the term to describe patients or their families (particularly in formal correspondence) is not acceptable; however, it remains useful when describing population groups. We support the move to using positive framing, but believe there is still a place for using \u2018vulnerable\u2019 within the College.
\nProfessor Graham Vimpani \u2013 Member of the CCCHC\nDr Sarah Loveday \u2013 Chair CCH Advanced Training Committee
Australasian Faculty of Public Health Medicine \u2013 Power in words\n
As physician Fellows and trainees, we are powerful advocates for the communities we serve. As words convey concepts and shape world views, it is imperative that we use precise and transparent language in the various roles we undertake. How we frame health as an issue has never been more far-reaching than in today\u2019s world of online platforms and instant communication. Whether we observe the effects or not, the language we employ each day can have immense ramifications on the lives of those around us.
\nThe word \u2018vulnerable\u2019 and similar terms such as marginalised, disadvantaged, disenfranchised, at-risk and underserved are widely used throughout health discourse (Munari 2021). Although these terms have been used with good intent to help identify needs and appropriately direct funding and resources, there are two predominant problems with this kind of terminology. \n
Firstly, the term vulnerable is indiscriminate and vague, concealing, in certain cases, the wider structural and systemic causes of health inequity. It is a term of convenience used strategically to draw political and financial attention to the issue in question (Katz 2019). Instead, we should use language that precisely and transparently identifies the underlying problem at hand, resisting temptation to label a population or group \u2018vulnerable\u2019. By adopting this approach, the true nature of the situation can be unveiled and targeted solutions better conceptualised and applied.
\nSecondly, the use of terms such as vulnerable is deficit language, implying an inherent inadequacy on behalf of the labelled. Such categorisation can create or reinforce a power imbalance between the labeller and the labelled, also implying an assumption of \u2018invulnerability\u2019 of the former. Use of such terms has elsewhere been likened to scientific racism, veering perilously close to biological determinism, eugenics and social Darwinism (Katz 2019).
\nAfter reading this, Fellows and trainees might ask, \u201cSo what term am I supposed to use instead?\u201d Yet the solution is not a simple matter of substitution. Ask yourself, \u201cWhy am I using this term?\u201d \u2013 moving from an unconscious to a conscious process. We aim to provoke thought and discussion on this concept and to challenge the reader to look beyond the term itself. \n
Before writing your article or giving your presentation to Grand Rounds, ask \u201cWhy is this person, group or community seen as vulnerable?\u201d Fellows and trainees hold positions of power in our communities by virtue of expert knowledge and respected positions within society. With this privilege comes the responsibility to advocate for our patients and communities in a way that respects and affirms those whom we serve. As a group, we are much more likely than many others to be economically comfortable and socially secure, so our choice of words is critically influential.
\nTo illustrate, people from refugee backgrounds living in Australia who are culturally and linguistically diverse have been described as vulnerable due to the high rates of mental health problems within this population (AIHW 2018). But why are these people vulnerable? Is it because they live in a predominantly English-speaking community with few services and supports that address their needs in an accessible way? Is it because they are unable to work in their trained professions and earn an adequate income due to immigration law and visa restrictions? These are worthy questions, even more worthy of comprehensive answers. Unpacking the \u2018why\u2019 invokes a wider lens and helps us identify the upstream structural influences on our community\u2019s health and wellbeing.
\nOthers have used the term \u2018vulnerable\u2019 to secure greater government attention for a cause or need. Yet this is counterproductive in the longer term, typecasting a population or group as desperate or without agency. There is no simple solution to this challenge. The College, in preparing its own media statements and advocacy position papers, must start asking \u201cwhy?\u201d and ensure that complete analysis is explained in its communications. Why are elderly people or Aboriginal and Torres Strait Islander people seen as vulnerable? What circumstances and societal factors contribute to the situation, for which the College defaults to using the term \u2018vulnerable\u2019? What exacerbates \u2018vulnerability\u2019? When you peak behind the curtain, the cause will often lie beyond the individual themselves.
\nThis point was powerfully conveyed by Cree\u2010Anishinaabe Assistant Professor Dr Marcia Anderson, Chair of the Indigenous Health Network for the Association of Faculties of Medicine at the University of Manitoba in Canada, when she Tweeted \u201cFrom now on instead of \u2018vulnerable people\u2019 I\u2019m going to use the phrase \u2018people we oppress through policy choices and discourses of racial inferiority\u2019. It\u2019s a bit longer but I think will help us focus on where the problems actually lie.\u201d (Anderson 2017, as cited in Munari 2021). Employing this kind of critical thinking readily unveils many of the upstream causes of health disparity and can help clarify strategic responses by more accurately describing the true determinants of the situation. This way of thinking also reminds us that a person\u2019s health and wellbeing is a culmination of biomedical, relationship, community and societal drivers that extend beyond the individual, as described by the socio-ecological model (Bronfenbrenner 1989, as cited in Kilanowski 2017).\n
Finally, consider strengths-based language. This way we can instead focus on what the population in question has to offer, rather than describing only a deficit. Strengths-based language is affirming, beneficial and respectful. It requires analysis of positive drivers of health and wellbeing for an individual, groups and communities. An example of such language is the use of \u2018priority population or communities\u2019. These are people for whom focused attention through funding and resources is required to work towards a more equitable health status (Blow 2020). A partnership approach is required to reduce the risk of irrelevant policy, programs or advocacy that miss the mark. Like any language used to define a population, strengths-based terminology should equally be clearly defined when used in discourse. Using such affirming language can also act to shift our attention towards an improved future and start to lay the bricks on the pathway needed to get there.
\nLanguage will continue to change and evolve, and it is our professional responsibility to stay abreast of how the language we use influences the opinions constructed in policy and practice. As physicians we are advocates. The obligation to reframe many of the issues affecting our community\u2019s health is not only in our hands but in our words.
\nStephanie C Munari, Trainee member, AFPHM Policy and Advocacy Committee, in collaboration with the AFPHM Policy and Advocacy Committee
References\nBlow, N. (2020). Improving COVID-19 Responses for Priority Communities using First Nations Health Principles. Victorian Gerry Murphy Prize Regional Competition Presentation. Sydney (AUST): Australasian Faculty of Public Health Medicine.\n\nBronfenbrenner, U. (1989). Ecological systems theory. In: Vasta R, ed. Annals of Child Development: Vol. 6. London, UK: Jessica Kingsley Publishers; 187\u2013249.\n\nKatz A, Hardy B, Firestone M, Lofters A, Morton-Ninomiya M. Vagueness, power and public health: Use of \u2018vulnerable\u2018 in public health literature. Crit Public Health. 30(4):1-11\n
\nKilanowski, Jill F. (2017) Breadth of the Socio-Ecological Model, Journal of Agromedicine, 22:4, 295-297, DOI: 10.1080/1059924X.2017.1358971
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Munari S, Wilson A, Blow N, Homer C, Ward J. (2021). Rethinking the use of 'vulnerable'. Australian and New Zealand Journal of Public Health. 3-. doi:10.1111/1753-6405.13
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