Vulnerable populations: an area CMAJ will continue to champion

CMAJ has chosen “vulnerable populations” as its fourth area of focus (alongside sepsis, health services and mental health). This is unlikely to surprise many readers. In its more than 100-year history, CMAJ has published much research showing that certain groups of patients who might be considered vulnerable have worse health outcomes than the general population. We have published many editorials and commentaries calling on Canada’s governments to reform health care delivery for vulnerable groups, from prisoners to drug users, refugees, those who are at risk of interpersonal violence, and the Aboriginal communities that experience shocking health inequalities. Now, by choosing vulnerable populations as a CMAJ area of focus, we renew our commitment to using our platform to advocate on behalf of Canadians who are vulnerable to poor health because of structural and personal factors that prevent them from achieving the optimal health that is their human right.

How do we define vulnerable populations? In a linked commentary, Clark and Preto consider in some depth the concept of vulnerability as it is conceived in health research and health care.1 To be vulnerable implies that an individual or group is at risk of coming to harm. All humans are vulnerable in some sense, but some are more at risk of being harmed than others, either because of some inherent factor or external factors (e.g., marginalizing policies, barriers to accessing opportunity, stigma or societal constructs). For the purposes of our area of focus, we classify vulnerable populations as those that experience adverse health outcomes compared with the general population by virtue of both internal and external factors. Broad populations, such as those in vulnerable life stages through which all humans will normally progress (i.e., children or older adults), will not be objects of our focus. Nor will those with specific diseases, even uncommon diseases, usually qualify, because nearly all of CMAJ’s content is about populations made vulnerable by or to a particular disease. Instead, we seek to focus on groups for whom an additional factor — e.g., poverty, isolation, discrimination, social disruption — renders them vulnerable through inadequate delivery of effective health care.

A recent CMAJ article2 called the staggering economic burden of health care inequalities and the burden of disease attributable to poverty, “a self-inflicted societal wound.” For decades, epidemiologists have documented health inequalities resulting from social determinants of health, but only recently have we begun to analyze and appreciate how much poverty, marginalization, oppression, racism and lack of social mobility actually cost society, and how much investment in reducing social factors that contribute to ill health can improve both health and health care efficiency.3 Because CMAJ’s mission is to champion knowledge that matters for the health of Canadians, we will continue to publish high-quality evidence and analysis that support policies most likely to reduce the burden of health inequalities on Canadian society. Furthermore, we intend to hold governments to account on this issue.

As the authors of the linked commentary point out, it is important that we do not further stigmatize the vulnerable through paternalistic labelling. It is not our aim to “box” people. We hope to shine a light on vulnerability in health care and help to reduce it by empowering and giving voice to those who are vulnerable. We are hereby signalling to researchers working with vulnerable populations across Canada and internationally that we can be a prominent home for their highest-quality work in this area. In addition, we will continue to prioritize CMAJ’s tradition of effective advocacy for the vulnerable. Our repeated advocacy over the past decade for Jordan’s Principle4 — which asserts that timely delivery of health services to First Nations children cannot be denied because of jurisdictional disputes over costs — helped to bring public attention to this issue, culminating in former Minister Philpott’s action last year to stop the federal government’s legal challenge to its implementation.

By announcing our fourth area of focus, CMAJ does not intend to neglect our mandate to publish a broad range of articles relevant to everyday medical practice. Advances in care for vulnerable populations are apt to provide advances for the general population as well. And the converse is also true. Advancing a more empowered and equal society is good public health medicine.