Vulnerability

If you go when the snow flakes fallWhen the rivers freeze and summer endsPlease see for me if she's wearing a coat so warmTo keep her from the howlin' winds

—Bob Dylan, Girl from the North Country

Here in Nashville, summer starts to end when the temperatures hover in the nineties, sometimes higher. The weeds dry out and seeds blow everywhere. Heat threatens most living things, and will for a while still, but then it fitfully abates, although not as much as in earlier years with the gentler climate we lived in then. Now tornadoes and floods loom more frequently in spring and summer, and in winter harsh ice storms and hail batter this part of the country, and do so less predictably and more frequently than they did in past years. In other parts of the country, drought, hurricanes, and blizzards dramatically punctuate long passages of oddly warm times. In Dylan's song to his lost love, he asks someone to protect her from such dangers. The planet itself is that girl now. Before turning to the contents of the present issue, we note with concern the United States' withdrawal from the Paris Agreement, part of the U.N. Framework Convention on Climate Change. As the effects of the warming planet are being and will be felt more forcefully by the less well-off Southern Hemisphere and by portions of the Northern Hemisphere already battered by economic blows (e.g., the U.S. Southeast and Midwest) we feel called upon to register our opposition to this withdrawal and our support for leaders of cities and states around the U.S. who have determined independently to exert power in order to limit environmental damage from carbon emissions. A team of scholars from the JHCPU editorial board will address this matter more fully in an upcoming issue.

Dylan's girl from the north country personifies vulnerability, a quality underlying much of the work in the present issue of JHCPU. A word or two about the notion of vulnerability: The terms social determinants of health and social-ecological model of health locate many of the concerns addressed in JHCPU in the maze of humanly created structures that segment human beings into groups and then place those groups in unequal positions relative to resources and circumstances that affect health. In contrast with the precision medicine being made possible by genomics, public health that concentrates on social determinants presupposes for the sake of argument that all else—all other than social-ecological factors—is equal among population groups, opting to look at health-related inequalities from a bird's eye view on social groups rather than from a microscope's view of individual biological profiles.

Vulnerability to adverse health and premature mortality might be associated with one's genetic profile or with one's social and ecological circumstances. An extensive family history of heart disease strongly suggests that an individual is vulnerable to the condition. A life of poverty, poor nutrition, stress, and exposure to environmental toxins strongly suggests the same vulnerability.

While generalizable to both individual (genetic) and societal circumstances, the idea of vulnerability brings to mind a more intimate understanding of human well-being and threats to it. Vulnerability connects with the long tradition of haptic medicine¹—of physical touch as a healing force—and draws out people's intuitive senses of justice and the need to protect the innocent. The vulnerable person needs help, but so too do the less vulnerable need to help: Dylan asks his listener to make sure, on his behalf, that his lost love has a coat warm enough to keep her from the howling winds.

A danger looms for people drawn to work on behalf of people less fortunate than themselves: they may end up patronizing and disempowering the very ones they seek to assist. Before proceeding further, then, we must affirm the vital nature of initiatives from people in need for people in need. We affirm the importance of populations subject to the howling winds of genetic and social vulnerability claiming and exerting power to counteract them on their own behalf...