Vulnerabilized: Revisiting the Language of the Vulnerable Populations Framework

Public health prioritizes the identification, mitigation, and elimination of health disparities, which are defined as preventable, inequitable differences in health risks and outcomes burdening socially disadvantaged populations. These patterns of disparities become more evident when aggregated from the individual to the population level. For example, Black women disproportionately face increased maternal morbidity and mortality outcomes as a result of social determinants of health, such as structural racism, social prejudices, biases, and policies.¹ Despite the urgent and ongoing need to address the underlying causes of these disparities, there remains a lack of formalized nomenclature that adequately encapsulates the complex, multifaceted systems that perpetuate vulnerability.² In response, we propose a novel technical term to augment the language of vulnerability.

Language that articulates differential risks among populations is rooted in the Belmont Report. This seminal document established protections to guard against the exploitation of vulnerable groups, specifically identifying “racial minorities, the economically disadvantaged, the very sick, and the institutionalized.”³ Building on the Belmont Report, the vulnerable populations framework situated individuals in the broader contexts of their communities and environments, recognizing the reciprocal relationships between the social determinants of health and health outcomes.⁴ Although existing definitions define vulnerability as susceptibility to harm or resulting from external influence, its ubiquitous use has eroded its meaning, often overemphasizing the influence of individual attributes while diluting the deterministic role of upstream determinants.^5,6

Although strides have been made to refine the concept of vulnerability, there remain challenges (e.g., inconsistency, ambiguity) and implications (e.g., gaps between theoretical and operational levels) that are necessary to consider when using vulnerability language and frameworks.⁷ The language of vulnerability can be deleterious when placing undue, deficit-oriented emphasis at the individual level, as doing so conceals the role of systemic factors in creating the processes and environments through which individuals, who aggregate into populations, are made vulnerable.⁸ Merely designating populations as vulnerable fails to identify the actions of systems of oppression that cause and maintain health disparities.

Recognizing this gap, we advocate a linguistic evolution from the passive adjective of vulnerable to the updated, transitive verb vulnerabilize to illustrate the ongoing process through which vulnerability is created and sustained. We define the term vulnerabilized as the outcomes of the processes, driven by distal systemic factors beyond the control of the individual or population, where heightened risks intersect and compound among various social identities and positions and result in differential, unjust, and preventable health differences.

Kimberlé Crenshaw coined the term intersectionality to describe the macro, structural perpetuations of systemic oppression, discrimination, and privilege that interact and manifest as health inequities and disparities.^9,10 A population’s multidimensional, compounding identities and positionings (e.g., race, ethnicity, sex, gender, immigration status) are crucial to consider, as they simultaneously intersect. The extant vulnerable populations literature alludes to related themes (e.g., layers of marginalization, integrated vulnerability, heterogeneity) but falls short of naming intersectionality.^6,7 This omission demonstrates the necessity to embed intersectionality in vulnerable populations discourse. Integrating intersectionality with the concept of vulnerabilized situates individuals within their macrolevel contexts, acknowledges the interaction of multiple forms of marginalization, emphasizes the need for systemic accountability, and prioritizes structural interventions attuned to these complexities to advance health equity.⁹

Vulnerabilized shares similarities with commonly used verbiage but offers a linguistic shift to acknowledge the nexus of underlying, and often obscured, upstream determinants that shape vulnerability.¹¹ Critiques of the terminology currently used to describe vulnerable populations point to its paternalistic and oppressive undertones, investment in maintaining social control, and contribution to stigmatization and exclusion by way of labeling and blaming while disregarding populations’ assets and agency.^8,12 A variety of terms are often erroneously used synonymously in the vulnerable populations literature without recognizing the risks of further perpetuating stigma, discrimination, inequity, and disparity.

The haphazard use and assumption of terms (e.g., marginalized, hard to reach, underprivileged) as interchangeable without consideration of their meaning risks oversimplifying complex, multidimensional concepts. For example, marginalized has become increasingly relied on to discuss populations burdened by health disparities when it might rather, more aptly, describe populations systemically pushed to the margins, or the periphery, who, as a result, have been vulnerabilized. Similarly, hard to reach has been employed to describe the perceived inaccessibility of populations without adequate acknowledgment of the role of marginalization in their distancing. These subtle, yet significant differences must be parsed out to avoid common pitfalls associated with misuse (e.g., exclusion, stigma).^8,12

As public health practitioners, we have a responsibility to intentionally select our language, given our understanding of how language perpetuates social norms, influences attitudes, guides actions, and determines priorities. Given the limitations of our current lexicon, coupled with the potential harms of inaccurate or inadequate terminology, we call for attention to be devoted to the intentional use of precise, descriptive language when discussing vulnerabilized populations. It is the responsibility of the field to acknowledge and address the inadequacies and impacts of commonly used language in contributing to the adverse conditions from which we draw priorities. Therefore, we propose a transition away from a dependence on broad, seemingly catchall descriptors to the conscientious use of precise terms, such as vulnerabilized, when appropriate and meaningful to effectively communicate pertinent distinctions in our current vocabulary.

Additionally, public health efforts must first actively collaborate with communities being labeled to ensure that descriptors not only resonate but also empower and validate lived experiences. Motivations for labeling populations should be weighed against their implications and effects. Approaches that safeguard autonomy (e.g., person-first language, community-based participatory research) and ownership of personal narratives, identities, and experiences should be prioritized.

In conclusion, framing health equity with the term vulnerabilized recognizes that populations are not ambiguously vulnerable but rather are vulnerabilized, which more aptly positions us to address the root causes of health disparities. Failing to consider the power of language used to convey vulnerability inadequately holds accountable the systems that create and maintain inequities and disparities at the expense of the populations we serve. Regardless of whether vulnerabilized becomes a widely accepted term, the importance of using intentional language cannot be overstated. This is not merely a call for a semantic adjustment but also a reorientation toward social justice–based equity efforts, beginning with language.

Although we have made the case for vulnerabilized, it is our hope that this is not the end of the conversation but rather the beginning, motivating public health practitioners to intentionally choose their language, collaborate with those being labeled, and consider the impacts of the language chosen to describe populations. Vulnerabilized offers a perspective through which stakeholders, researchers, practitioners, and policymakers can better understand and address the systemic origins and evolving dynamics of vulnerability among individuals and populations.