Book Review Editor's Introduction

The health of and health care provided for vulnerable populations now command substantial attention. Numerous recent studies, government reports, and media stories show that members of such populations, particularly minorities, are in poorer health and receive inferior care compared with other populations. The essays and reviews in this symposium highlight the normative dimensions of this attention, three of which deserve emphasis.

First, the category "vulnerable population" is in part a social construction. The word vulnerable imparts a judgment that the population's members are not at fault for their condition, which instead results from social pathology. Accordingly, use of this word is inapposite if a particular disease in a given time and place is perceived to result from individual fault (e.g., "neurosis"); nor could this word apply to a disease that is taken to be a marker for the biological or cultural inferiority of a certain sex, ethnic group, or race (e.g., "sexual behaviors"). Conversely, the biological sword can be used as a shield when disease is taken to be biologically based (e.g., "physiologically based mental illness"). Many of the reviews in this symposium show that these meanings are contested in social and political processes that assign responsibility to individuals, society, and nature.

A second and related normative dimension concerns the amounts, sources, and directions of resources that address the situation of vulnerable populations. Examples abound. Substantial resources are spent to protect "innocent victims" of blood-borne diseases like HIV, while efforts like syringe-exchange programs for intravenous drug users are underfunded or even prohibited. The U.S. National Institutes of Health spends a far greater proportion of its resources on treatments for AIDS than on interventions that might prevent its spread. Treatments are available largely just to the world's insured populations, and rights to their sale and distribution inure to the benefit of the pharmaceutical industry. Insurance coverage for mental illness that is caused by brain chemistry is generally more fully insured because it is not subject to "moral hazard." Although it would be foolish to attribute these priorities to purposive choices, social and political processes concerning blame and worth play a role.

Third, because norms are constitutive of daily life on a much more microlevel--relationships to self and to others in daily interaction--"vulnerability" captures the extent to which populations stand at the margins of or are integrated into the social fabric. Social isolation, self-hate, and self-blame are horrible aspects of disadvantage yet are invisible in population studies that are unable to "drill down" to the world of daily life. The fact that it is vulnerable populations that receive so much attention itself is indicative of a certain social distancing.

The works in this review symposium on the health of and health care for vulnerable populations address such themes. They are offered as a means of understanding what the attention to vulnerable populations reflects about our society.