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Using the concept of vulnerable populations, we examine how disparities in health may be exacerbated by populationapproach interventions.
We show, from an etiologic perspective,howlife-course epidemiology, the concentration of risk factors, and the concept of fundamental causes of diseases may explain the differential capacity, throughout the risk-exposure distribution, to transform resources provided through population-approach interventions into health. From an intervention perspective, we argue that population-approach interventions may be compromised by inconsistencies between the social and cultural assumptions of public health practitioners and targeted groups.
We propose some intervention principles to mitigate the health disparities associated with population-approach interventions. (Am J Public Health. 2008;98:216-221. doi:10.2105/AJPH.2007.114777)
IN WESTERN SOCIETIES, significant efforts during the last half century to improve health systems have resulted in spectacular gains for a wide range of health indicators.1 A growing number of studies, however, show that these gains have not benefited everyone equally; inequalities in health seem to have increased, at least for some health outcomes.2-4 This unexpected consequence is particularly troublesome in the case of population-level interventions, which seek to improve the health of the entire population.
We distinguish between 3 intervention approaches: the populations-at-risk approach, based on Lalonde's notion of the health field5; Rose's population approach, 6 which addresses the conditions shaping the distribution of individual risk in a population; and a vulnerable population approach that addresses the conditions that put social groups "at risk of risks"-that is, risks that generate exposure to other risks. By shifting the focus to whole populations, populationlevel interventions, which are based on Geoffrey Rose's population approach, represented an advancement over a populationat-risk approach.
We propose, however, that interventions based on population approaches are not free from criticism and may have led to unintended exacerbations of health disparities. Using the concept of vulnerable populations, we attempt to explain how this can be so. We begin by reviewing the notion of "populations at risk" and its relationship to Rose's population approach and then proceed with a critique of Rose's approach based on the notion of vulnerable populations. We conclude by suggesting that interventions addressing the needs of vulnerable populations should be used as a complement to population approaches.
LALONDE'S NOTION OF "POPULATIONS AT RISK"
The Lalonde Report,5 published in Canada in 1974, constitutes a landmark in public...