Global Health Challenges: Social Exclusion and its Detrimental Effects on Health
The concept of social exclusion has been around for a long time however the phrase social exclusion became (certainly in the UK) popular in the late 1990s. It first appeared in policy documents in those of the European Union and in the UK the labour government, voted in 1997, and adopted it in many of its policy documents. It is used to depict people who, for variety of reasons are excluded from mainstream society. Lifestyle can exclude people from mainstream society, the traveller communities in the UK and Ireland are excluded from mainstream society, as are the Bedouins in North Africa.
Particular circumstances can exclude people; refugees coming into another country are excluded from the host country’s mainstream society; another group who can be fairly consistently excluded are disabled people. Of course, a number of people can exclude themselves by choice from the activities of society; people of wealth can afford to buy alternatives, and thereby exclude themselves. Social exclusion is a complex phenomenon and many factors are involved, but very often money is tied up with exclusion issues and a lack of money can prevent many people from participating in society, it is usually due to poverty that many people find themselves excluded.
Exclusion can be at a local, national and international level. At a local level it can be that many are excluded due to lack of money to participate in many of the activities that their neighbours are undertaking, they see their friends and neighbours affording certain amenities that they cannot afford themselves. Often people lack the resources to buy even the basic necessities of life. In developed countries there are many struggling to make ends meet. The web-based game SPENT, illustrates this point and demonstrates, for those on limited income, how easy it is to become excluded.
Often whole neighbourhoods can be excluded and Wacquant discusses how in large US cities, policy decision can create ghettos in large cities, where people are forced to live not because of military rule or enforced law but because of poverty and a lack of alternatives. While often not as obvious but this is replicated throughout the world, where there are deprived areas with a clear lack of amenities. Additionally, often wealth is created in large cities and tends to stay there, resulting in a divide between rural and urban areas and in cities themselves. In the UK the south is seen as more prosperous and the north as much less so.
At an international level many countries are in a variety of ways excluded from the world stage, Sen. Although it is a concept originating in Europe, it usefully can be applied to other countries. DuToit examines South Africa and discusses the complexity of social exclusion. He makes the point that on an international level, it is not so much being excluded but being included on less favourable terms can be detrimental.
The above discussion demonstrates the multidimensional nature of the term social exclusion and also demonstrates the complexity of exclusion. Whilst it is a complex phenomenon and many factors are involved, a fairly common factor is poverty and the unequal distribution of resources. Its relationship to health is again very complex but poorer people tend to have poorer heath than their more affluent neighbours. This was illustrated in the Black Report, which linked ill health to social inequalities such as education, housing income. Of course, ill health can lead to poverty and poverty can exacerbate illness.
In many situations people may not have the money to buy drugs or obtain treatment. Even in the United Kingdom where there is a National Health Service with healthcare free at the point of delivery; care is unequal with economically poorer areas generally having poorer health provision. As early as 1971 Dr Julian Tudor Hart describe this as the “inverse care law”, health provision is inversely related to the needs of the population, and those who need it most have less provision. All this supports the argument that those excluded tend to have poorer health than those more integrated in main stream society.
Much of this is tied up with poverty however the relationship is more complex as the following examples will illustrate. Richard Wilkinson and Karen Pickett on the basis of their epidemiological study concluded that countries were the gap between the rich and the poor are widest do have the highest level of health and social problems, as illustrated by eleven indicators such as physical and mental health, violence and teenage pregnancy. Countries like the United States of America and the United Kingdom do not come out well against these indicators. This point is further illustrated in a further study undertaken in Ireland that examined traveller health and found that travellers have a higher rate of mortality than the general population and cardiovascular, respiratory diseases and suicide rates are higher than the rest of the population.
1. Wacquant, Loïc (2008) .Urban Outcasts: A Comparative Sociology of Advanced Marginality. Cambridge: Polity Press
2. Sen A (2000). Social Exclusion: Concept, Application, and Scrutiny. Social Development Papers No. 1.Asian Development Bank
3. Du Toit, Andries (2004). ‘Social Exclusion’ Discourse and Chronic Poverty: A South African Case Study Development and Change 35(5) :987–1010,
4. Townsend, P & Davidson, N (1982). Inequalities in Health: Black Report Pelican Series, Penguin Books
5. Hart J.T. (1971) The inverse care law. Lancet. 27 (1):405-12
6. Wilkinson, R and Pickett, K (2009). The spirit level: Why greater equality makes societies stronger London: Bloomsbury Press
7. All Ireland Traveller Health Study Technical (2010). Report 1. Dept of Health and Children, Dublin available at http://www.dohc.ie/publications/traveller_health_study.html accessed 23/1/13
About the Author: John Fulton has a career pathway spanning 25 years in the field of Mental Health Nursing and Clinical Education. He has extensively worked in the context of undergraduate and postgraduate healthcare and his research interests reflect a commitment to social theoretical perspectives in health and social care. He is currently a Principal Lecturer in the Faculty of Applied Sciences working predominantly with professionals undertaking doctoral level study. He can be reached at [email protected]
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