Vulnerability: An article for CMJI

From an article for a special issue of Christian Medical Journal of India on vulnerability published in December 2018 [Download issue here]

The word Vulnerability, like many other words in modern English, comes from late Latin vulnerābilis (wounding) or vulnus (wound), according to Webster’s dictionary. In its current use, the word carries a wider meaning beyond impending physical injury or harm, to include the risk of emotional or psychological trauma. It has been widely used in the context of natural disasters. Sudden and often unforeseen natural calamities put a lot of people at physical, socio-economic, political, psychological and emotional harm. However, vulnerability is not only about large populations and natural disasters; individuals or households too can experience vulnerability due to various psychosocial, familial or other life circumstances. In either case – be it individuals or populations – an experience of vulnerability is almost never exclusively due to the individual’s own choices. A large body of work from social sciences, as well as stories and narratives of people who have dealt with vulnerabilities in their life, demonstrates that this experience is almost never caused in isolation. 

Social construction of vulnerability

While discussing vulnerability in a recent book on health inequities in India edited by Gaitonde & Ravindran (2018), Chitra Grace quotes from an article by Mechanic and Tanner in the journal Health Affairs (2007): “The likelihood that the person becomes vulnerable depends on the intensity of the stressors experienced and the resources (education, income and wealth, cognitive ability, the support from families, social networks and community resources) available to manage the situation”. Clearly, access to resources and belonging to particular social groups modulates the vulnerability experience; while some of us may come out unscathed from a given illness experience, it could devastate others merely because of their social circumstances. This so-called social construction of vulnerability is an important insight for all of us in the health sector because it clarifies that vulnerability need not always arise from the health problem or condition. It is important to distinguish a particular health problem or condition that may transiently cause disruption or weakness or ill-health, from the social reaction of people in relative power and social position which may accentuate the experience of this illness. For instance, being pregnant is in itself not “vulnerable”; pregnancy merely changes the needs of the woman transiently. However, a pregnant woman in an urban poor neighbourhood or a pregnant woman in an abusive relationship experiences the vulnerability of pregnancy differently. Hence, the vulnerability here is mediated through existing gender-dependent relationships and socio-economic inequities. This is similar to the experiences of stigma and discrimination faced by people living with particular health conditions, wherein the ill-health effects of the health problem can be relatively easily managed (with bio-medical treatment options), while the experience of stigma and discrimination stemming from societal norms amplifies the ill-health effects. In the book cited earlier, Grace quotes from Carol Hill’s account of a person with disability

“All my life I’ve been told that I can’t get into my neighbourhood restaurant because my legs won’t take me upstairs. Now I know it’s because the restaurant owner won’t build a ramp.”

People are often rendered vulnerable by the social and policy environment that does not accommodate and address their physical and psychological needs and differences. 

Some vulnerable groups experience stigma and discrimination which compound their disadvantages and powerlessness. One example is people living with severe mental illnesses, who, in addition to their psychological vulnerability, face economic vulnerability because of social attitudes to employing persons with mental illness, as well as social exclusion and isolation because of stigma and discrimination making them socially vulnerable. Gender is another powerful illustration of how biological differences gets socially transformed into possible disadvantages for one gender over another. So, what tends to be a biological difference becomes a social disadvantage. The socially constructed disadvantages albeit operating only in particular circumstances may often lead to a different social status (than men), relative lack of power in households or in workplaces, and disadvantaged access to and control over resources, none of these being attributable to the biological difference. Being vulnerable is a matter of lack of power. Not only gender; other population groups struggle with scarcer choices and more barriers in access to resources. Furthermore, when state-provided health and social care services are weak or non-existent, this, in turn, creates a vulnerability where previously there were none. 

Not randomly distributed

Nation-wide patterns of health outcomes tell us that poor health outcomes systematically aggregate in specific population groups. This tells us something important; that this clustering of the risk of ill-health could be a consequence of how we have organised our services, systems and resources. Households, communities and human societies on one hand, and various systems that we create for ourselves (including the health system, or the agro-ecological system for example) tend to create, amplify (or sometimes mitigate/modify) conditions that bring about vulnerabilities. In our society, there are various axes along which vulnerability gets created, amplified or perpetuated. The biggest among them are caste, socio-economic status and gender. Several rounds of data from the periodic national health and family surveys tell us that some population groups consistently fall behind in terms of health status, nutrition, longevity and quality of life. Those vulnerable in terms of physical needs include, for example, persons living with physical disabilities, pregnant women and children at high risk of morbidity or mortality, those suffering from chronic physical health conditions, and persons living with HIV/AIDS. Those living with serious or common mental disorders, having a history of alcohol or substance use or are suicidal may be considered as psychologically vulnerable. In addition to several population groups defined by specific health problems that render them more vulnerable than others, individuals living in abusive or dysfunctional families are very vulnerable. At the same time, entire populations may experience social exclusion, for instance, migrants or refugees. 

Dealing with varied life experiences

One of the barriers in responding to vulnerability is often the lack of familiarity with the specific vulnerable situation due to health workers/professional’s own lack of having experienced the particular experience that results in the person feeling vulnerable. This means that health and social workers need to be able to recognise and respect differences in terms of the life experiences of people that we work with. Vulnerable individuals/populations are often dealing with a life experience that is not widely shared and this may cause us to overlook the drivers of such vulnerabilities and compromise our ability to deal with vulnerable individuals with respect and dignity. 

Vulnerability can be addressed by health workers

While indeed being grim, vulnerabilities of individuals/populations ought to strengthen our resolve towards mitigating them. What is socially constructed – arguably – could also be socially dismantled? It appears so, but clearly, such an endeavour needs a deep acknowledgement of the existence of such inequities within our families, villages/towns and societies. Most importantly, it also reminds us that the acknowledgement and action on vulnerabilities is as much an individual journey, as it is that of households, communities and societies. And health and social workers including doctors, nurses, para-medical staff in government, non-profit or private sector can modify the effects of such vulnerability by (a)recognising their existence, (b)recognising how vulnerabilities can manifest differently in different individuals (even within the same family), and finally, (c)being empathetic to the specific needs imposed by the physical, emotional or social vulnerability that individual patients, caregivers or others are dealing with. In addition, we need to realise that addressing social vulnerability also needs us –  health professionals, health workers and social workers – to embrace a rights-based approach to health, wellness and dignity. It is the duty of those who are in a relative position of power – having a voice on the health of people – to advocate for systems and services that build resilience; a system of care that empowers individuals and populations rather than see them as passive beneficiaries of generosity. Health and social systems of care need to be strengthened in the long run in order to address social vulnerability.  

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