The impact of neglecting unearned advantage

We thank Beth Clark and Nina Preto for their recent article, “Exploring the concept of vulnerability in health care.”1 We appreciate their analysis of the term “vulnerable” and other terms used to describe groups at increased risk for poor health, particularly in the context of CMAJ’s recent focus on “vulnerable populations.”

We appreciate that the authors offer caution regarding the ways that words like vulnerable can perpetuate paternalism, oppression, social control, stigma and disempowerment; we agree that the term “underserved” can highlight that the root of the problem is the system rather than the individuals with worse health.

Yet, the authors could have gone further in their analysis.

The problem is not only that some people are more vulnerable to illness, or that systems of inequality — including colonialism, racism, ableism and sexism — give some groups unearned disadvantage, which can lead to being underserved. The direct corollary of unearned disadvantage is the unearned advantage that other groups receive from these same systems of inequality. Missing from Clark and Preto’s article is recognition that systems of inequality that cause harm to vulnerable groups also directly benefit others, leading to better health, increased wealth and increased political capital.

Leaving unearned advantage out of conceptualizations of inequity or vulnerability is harmful insofar as it reinforces the patterns that produce vulnerability. First, omitting unearned advantage reproduces and thereby reinforces inequity by positioning those who are vulnerable or underserved as helpless and those who are recipients of unearned advantage as experts whose role it is to help. We then create solutions to address “the problem” of those who are vulnerable or underserved without also framing those with unearned advantage as part of the problem.

Worse still, neglecting unearned advantage allows and encourages those who work with marginalized populations to be positioned as neutral and unconnected to the systems of inequality that produce vulnerability — and therefore worthy of praise for their altruism, courage and selflessness for doing this work — instead of being complicit in and a central part of systems of inequity.

To dismantle systems of oppression and inequality, and the negative health effects of unearned disadvantage, we must attend to the ways in which we are all part of systems of inequality. We can either remain blind to our complicity in these systems and thereby knowingly and unknowingly reinforce them by our everyday actions or come to understand our positions of unearned advantage so that we can resist these patterns.

Good intentions are not enough. The focus needs to be on impact. And the impact of neglecting unearned advantage in discussions of vulnerability is deeply harmful.