SDOH-Listserv Bulletin No. 3, February 9, 2004
Social Exclusion and Health
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Introduction
The recent emphasis on social exclusion developed from a variety of
European policy initiatives that continue to this day. A related concept,
social inclusion, has been the focus of much activity in Canada. There has
been much less concern with the idea of social exclusion within the USA.
The importance of social exclusion to health was recognized early by
poverty researchers. In 1979, Peter Townsend defined the relationship of
poverty to exclusion:
Individuals, families and groups in the population can be said to be in
poverty when they lack the resources to obtain the type of diet,
participate in the activities and have the living conditions which are
customary, or at least widely encouraged or approved, in the societies to
which they belong. Their resources are so seriously below those commanded
by the average individual or family that they are, in effect, excluded
from ordinary living patterns, customs and activities (Townsend, 1979,
p.31).
More recently, Smeeding and Rainwater (2003) argue that:
" Poverty in this view is a persistent shortfall of resources that
results in a person not being able to act out mainstream social
roles?From this perspective, a social minimum is defined as a certain
minimum of possessions in order for the family to meet cultural
definitions of a family (p. 146-147).
"Nothing in this conception of poverty implies that this definition of
poverty is merely subjective, or even that poverty is defined
consensually. Rather, the argument is that objectively people cannot
carry out the roles, participate in the activities, or maintain the
social relations that are definitive of mainstream members of a society
(p. 147).
Social exclusion is now recognized as a prime social determinant of
health (Wilkinson and Marmot, 2003). The concept of social exclusion
provides a useful means of understanding how various social determinants of
health such as low income, poor housing, and food are interrelated and come
to affect health (Shaw et al., 1999). The concept of social exclusion also
describes an overall process by which citizens are adversely affected by
governmental social and economic policies and other societal processes
(Byrne, 1999). Contemporary definitions of social exclusion include:
"Social exclusion is defined as a multi-dimensional process, in which
various forms of exclusion are combined: participation in decision-making
and political processes, access to employment and material resources, and
integration into common cultural processes.
When combined they create acute forms of exclusion that find a spatial
representation in
particular neighbourhoods" (Madanipour et al., 1998).
"Exclusion processes are dynamic and multidimensional in nature. They are
linked not only to unemployment and/or to low income, but also to housing
conditions, levels of education and opportunities, health,
discrimination, citizenship and exclusion in the local community"
(EUROPA, 1994).
Social exclusion is a process by which people are denied the
opportunity to participate in civil society; denied an acceptable supply of
goods or services; are unable to contribute to society, and are unable to
acquire the normal commodities expected of citizens (Byrne, 1999). All of
these elements occur in tandem with the material deprivation, excessive
psychosocial stress, and adoption of health threatening behaviours related
to living in low-income circumstances (see SDOH Bulletin 2, February 2,
2003).
The value of the concept is that it recognizes that exclusion from
society happens to people as a result of societal change and government
policy rather than being a characteristic of individuals such as poverty.
The processes that lead to social exclusion include economic changes such
as increased unemployment or widespread job insecurity. It also includes
demographic changes such as an aging population or single parent families,
changes to welfare programs such as cuts and withdrawals, discrimination
and systematic exclusion from societal participation, and specific
processes of geographical segregation and isolation of certain groups such
as those with low income. Government policies are especially important in
either increasing or decreasing the extent of social exclusion within a
society (Shaw et al., 1999).
For example, Bryant (2003) shows how housing and related income
policies have a direct effect upon the quality of a variety of social
determinants of health, including social exclusion. When government
policies reduce the availability and affordability of housing, excessive
material resources must be allocated to maintain housing. The deterioration
of these social determinants leads directly to social exclusion and
deterioration in health status.
People can go without many things, but lack of housing is potentially
catastrophic. If citizens are required to spend increasing proportions
of available monetary resources on maintaining a roof over their head,
the resources available to support social determinants of health such as
food, educational resources, and others is diminished (Bryant, 2003).
The inability to spend resources on these other activities represents the
process of social exclusion.
The Concept of Social Exclusion
Grace-Edward Galabuzi has provided an extensive analysis of the
concept of social exclusion and its specific relation to the current
Canadian scene. His analysis has implications for most other developed
nations.
"Social exclusion is used to broadly describe both the structures and the
dynamic processes of inequality among groups in society which, over time,
structure access to critical resources that determine the quality of
membership in society and ultimately produce and reproduce a complex of
unequal outcomes. Social exclusion is both process and outcome. While
it has its roots in European social democratic discourse, it has been
increasingly embraced by mainstream policy makers concern about the
emergence of marginal subgroups who may cause a threat to social cohesion
in industrial societies. In industrialized societies, social exclusion
is a by-product of a form of unbridled accumulation whose processes
commodify social relations and intensify inequality along racial and
gender lines."
"White has referred to four aspects of social exclusion. Social
exclusion from civil society through legal sanction or other
institutional mechanisms, as often experienced by status and non-status
migrants. This conception may include substantive disconnection from
civil society and political participation, because of material and social
isolation, created through systemic forms of discrimination based on
race, ethnicity, gender, disability, sexual orientation, and religion. In
the post-September 11 era, racial profiling and new notions of national
security seem to have exacerbated the experience of this form of social
exclusion. Secondly, Social exclusion refers to the failure to provide
for the needs of particular groups - the society's denial of (or
exclusion from) social goods to particular groups such as accommodation
for persons with disability, income security, housing for the homeless,
language services, sanctions to deter discrimination. Third, is
exclusion from social production, a denial of opportunity to contribute
to or participate actively in society's social, cultural activities. And
fourth, is economic exclusion from social consumption - unequal access to
normal forms of livelihood and economy" (Galabuzi, 2004).
See Grace-Edward Galabuzi's powerpoint presentation "Social Exclusion" from
the 2002 Social Determinants of Health Across the Life-Span Conference at
http://www.socialjustice.org/subsites/conference/presentations/galabuzi_files/frame.htm
.
From Social Exclusion in Europe to Social Inclusion in Canada
The concept of social exclusion is a distinctly critical concept
emphasizing structural and power relations within a society. Within
Canada, the implications of the idea and the consequences of increasing
marginalization of significant numbers of citizens has led to increasing
focus on the practical process of promoting social inclusion.
I. Health Canada Atlantic Region Activities
The importance of social inclusion in Canada was first recognized by
Health Canada's Atlantic Region Population and Public Health Branch staff.
They commissioned the work by Jane Guildford "Making the Case for Social
and Economic Inclusion" (Guildford, 2000)
http://www.hc-sc.gc.ca/hppb/regions/atlantic/pdf/social.pdf and have gone
on to develop an extensive program of promoting social inclusion.
An Inclusion Lens
http://www.hc-sc.gc.ca/hppb/regions/atlantic/pdf/inclusion_lens-E.pdf
One of these related projects saw the completion of "An Inclusion
Lens: Workbook for Looking at Social and Economic Exclusion and Inclusion."
This is described as: "Social and economic exclusion and inclusion have
emerged as new ways of understanding poverty and disadvantage and their
impacts on well-being, by creating a shared understanding across sectors
and jurisdictions. An Inclusion Lens is a 20-page workbook for analyzing
legislation, policies, programs, and practices to determine whether they
promote the social and economic inclusion of individuals, families, and
communities.
It is designed for use by policy makers, program managers, and
community leaders who work in the context of social and economic exclusion
in the public and non-profit sectors. It is also a tool for activists in
social movements, women, people with disabilities, and community developers
working toward healthy, sustainable communities.
The Lens provides a method for analyzing both the conditions of
exclusion and solutions that promote inclusion. It provides a way to begin
a dialogue with excluded groups, raise awareness about how exclusion works,
and identify steps to move towards more inclusive policies, programs, and
practices. The Lens describes elements of inclusion and exclusion along
eight dimensions, and provides a workbook to guide analysis of policies and
programs and to plan action to promote inclusion."
The Atlantic Region Project http://www.acewh.dal.ca/inclusion-preface.htm
"The Inclusion Project is a partnership project facilitated by the
Maritime Centre of Excellence for Women's Health (MCEWH) and funded by the
Population and Public Health Branch of Health Canada, Atlantic Region
Office. The Project fosters links, networks and partnerships across
research community sectors. There are three provincial reference groups in
the four Atlantic provinces, consisting of key government and
community-based representatives with experiences and interest in public
policy development. They have come together to consider the problem of
poverty and the shift in thinking away from a concentration of child
poverty and towards an analysis of social and economic exclusion of women
and their children."
The Atlantic Region's Health Canada website provides more information about
inclusion initiatives:
http://www.hc-sc.gc.ca/hppb/regions/atlantic/documents/e_abs1.html.
2. Laidlaw Foundation Initiative on Social Inclusion
http://www.laidlawfdn.org/programmes/children/agenda-desc.html
"Building Inclusive Cities and Communities is the new focus of the
Children's Agenda Program of the Laidlaw Foundation in Canada. It follows a
two-year process whereby the Foundation adopted social inclusion as a tool
for evaluating and advancing social policy in support of children and
families. As part of the process, the foundation has commissioned 12
working papers on that have contributed to understanding social inclusion
and pointed to the importance of cities and communities as places where
inclusion and exclusion are first experienced by children and families."
Publications include:
1. Dynamics of Social Inclusion: Public Education and Aboriginal People
in Canada --Terry Wotherspoon
2. The Role of Recreation in Promoting Social Inclusion -- Peter
Donnelly and Jay Coakley
3. Poverty, Inequality and Social Inclusion --Andrew Mitchell and
Richard Shillington
4. Social Inclusion, Anti-Racism and Democratic Citizenship -- Anver
Saloojee
5. Thumbs Up! Inclusion, Rights and Equality as Experienced by Youth
with Disabilities -- Catherine Frazee
6. Immigrant Settlement and Social Inclusion in Canada -- Ratna Omidvar
and Ted Richmond
7. Social Inclusion as Solidarity: Rethinking the Child Rights Agenda --
Michael Bach
8. Social Inclusion Through Early Childhood Education and Care -- Martha
Friendly and Donna S. Lero
9. Feminist Perspectives on Social Inclusion and Children's Well-being
-- Meg Luxton
10. Ethical Reflections on Social Inclusion --Dow Marmur
11. Leave No Child Behind! Social Exclusion and Child Development --Clyde
Hertzman
12. Does Work Include Children? The Effects of the Labour Market on
Family Income, Time and Stress --
Andrew Jackson and Katherine Scott
13. Literature Review on Social Exclusion in Europe -- Pedro Barata
14. Social Cohesion Bibliography -- David Welch
The transformation of the concept of social exclusion into social inclusion
has not occurred without some critical analyses. Ronald Labonte comments:
"The latest construct being wielded by health practitioners, researchers
and policy-makers are the twinned concepts of social inclusion and social
exclusion. These represent sophistication over social capital and social
cohesion. Like their predecessors, however, there are risks in their
adoption with a critical examination of the premises that underpin them.
For example, how can one "include" people and groups into structured
systems that have systematically "excluded" them in the first place?
Their utility, particularly at a time when not only inequalities, but
also their rate of growth, is increasing, requires careful questioning"
(Labonte, 2004).
See Ronald Labonte's powerpoint presentation "Social Inclusion/Exclusion:
Dancing the Dialectic" from the 2002 Social Determinants of Health Across
the Life-Span Conference
http://www.socialjustice.org/subsites/conference/presentations/labonte_files/frame.htm
.
3. The UK Social Exclusion Initiative
http://www.socialexclusionunit.gov.uk/
The Social Exclusion Unit was set up by the UK Prime Minister to help
improve Government action to reduce social exclusion by producing
'joined-up solutions to joined-up problems'. It provides an example of how
a government is defining the problem and attempting to resolve it. "Social
exclusion is a shorthand term for what can happen when people or areas
suffer from a combination of linked problems such as unemployment, poor
skills, low incomes, poor housing, high crime environments, bad health and
family breakdown.
The Unit has produced numerous reports including "Preventing Social
Exclusion" (Social Exclusion Unit, 2001). All of their many reports are
available for downloading at
http://www.socialexclusionunit.gov.uk/published.htm. Their most recent
projects "Barriers to employment and enterprise in deprived areas" will
examine what more can be done to help people in England's most deprived
areas move into jobs and "Mental health and social exclusion" will address
the barriers to opportunity faced by adults with mental health problems.
Details concerning these projects are available at
http://www.socialexclusionunit.gov.uk/current_projects.htm.
4. Monitoring Poverty and Social Exclusion http://www.poverty.org.uk/intro/
Produced by New Policy Institute with support from the Joseph
Rowntree Foundation, this site monitors what is happening to poverty and
social exclusion in the UK and complements annual monitoring reports. The
material is organised around 50 statistical indicators covering all aspects
of the subject, from income and work to health and education.
5. Work in Ireland
Sara Burke's paper "Setting health targets for the National
Anti-Poverty Strategy"examines social exclusion in relation to poverty,
social exclusion and health inequalities in the Irish context. It draws on
European literature to provide a summary for an Irish audience with
relevant references. It can be found at http://www.publichealth.ie/ in the
publications section.
The Economic and Social Research Institute carries out research in
Ireland on social exclusion:
http://www.esri.ie/search_research.cfm?centerresearch=1&t=current&mId=3
6. Other Resources
I. Galabuzi, G., 2001. Canada's Creeping Economic Apartheid: The economic
segregation and social marginisation of racialised groups. Toronto: CJS
Foundation for Research & Education. On line at
http://www.socialjustice.org.
This report calls attention to the growing racialisation of the gap between
the rich and poor, that is proceeding with minimal public and policy
attention, despite dire implications for Canadian society. It challenges
common myths about the economic performance of Canada's racialised
communities and shows how historical patterns of differential treatment and
occupational segregation in the labour market, and discriminatory
governmental and institutional policies and practices, lead to the
reproduction of racial inequality in other areas of Canadian life.
Also see Galabuzi's "The Contemporary Struggle against Racism in Canada" in
the Jan/Feb 2004 issue of Canadian Dimension at
http://www.canadiandimension.mb.ca/v38/v38_1gg.htm
II. Policy Responses to Social Exclusion: Towards Inclusion? Janie
Percy-Smith (Ed.). (2000). London UK: Open University Press.
A definitive UK analysis of social exclusion, its processes and causes. It
contains numerous chapters concerned with presenting possible policy
solutions to this emerging problem.
III. Ornstein, M. (2002). Ethno-Racial Inequality in Toronto: Analysis of
the 1996 Census. Toronto: Institute for Social research. On line at
http://ceris.metropolis.net/Virtual%20Library/Demographics/ornstein1.pdf
A careful analysis of the growing gap in income among people of different
races in Toronto, Canada's largest city.
IV. The Centre for Analysis of Social Exclusion (CASE)
http://sticerd.lse.ac.uk/case/
CASE is an ESRC Research Centre, core-funded by the Economic and Social
Research Council since October 1997. CASE is a multi-disciplinary research
centre located within the Suntory and Toyota International Centres for
Economic and Related Disciplines at the London School of Economics and
Political Science.
V. Hills, J., Le Grand, J. and Piachaud, D. (eds.) (2003).Understanding
Social Exclusion. New York: Oxford University Press.
This book asks three main questions: How can social exclusion be measured?
What are its main determinants or influences? And what policies can reduce
social exclusion? The authors aim to consider how a focus on social
exclusion may alter the policy questions that are most relevant by
fostering debate in government, research, and academic circles.
VI. Townsend Centre for International Poverty Research
http://www.bris.ac.uk/poverty
The Centre was was launched on 1st July 1999 at the University of Bristol.
It is dedicated to multidisciplinary research on poverty in both the
industrialised and developing world.
VII. Social Science Information Gateway's has an exhaustive index of social
exclusion resources at
http://www.sosig.ac.uk/roads/subject-listing/Europe/poverty.html
VIII. Innocenti Working Papers, Innocenti Research Centre contains a number
of papers about exclusion in the USA, New Zealand, English-speaking nations
and elsewhere. At http://netec.mcc.ac.uk/WoPEc/data/ucfinwopa.html
IX. Other References
General
Bryant, T. (2003), The current state of housing in Canada as a social
determinant of health. Policy Options 24:3, 52-56. At
http://www.irpp.org/po/archive/mar03/bryant.pdf
Byrne, D. (1999), Social Exclusion, Open University Press,
Buckingham.
EUROPA (1994), European Social Policy White Paper, summary available
at http://europa.eu.int/scadplus/leg/en/cha/c10112.htm
Madanipour, A., Cars, G. and Allen, J. (1998), Social Exclusion in
European Cities, Jessica Kingsley, London.
Shaw, M., Dorling, D. and Davey Smith, G. (1999), Poverty, social
exclusion, and minorities in Marmot, M. G. and Wilkinson, R. G. (Eds.),
Social Determinants of Health, Oxford University Press, Oxford, UK.
Townsend, P. (1979) Poverty in the United Kingdom, a Survey of
Household Resources and Standards of Living, (London: Penguin Books and
Allen Lane).
Wilkinson, R. and Marmot, M. (2003), Social Determinants of Health:
The Solid Facts, 2nd edition. World Health Organization Europe Office:
Copenhagen. Available at
http://www.who.dk/document/e81384.pdf
X. Other Key International and National Resources
Organization for Economic Cooperation and Development
The OECD Bookstore has three important sets of analyses of how
nations deal with social assistance and social exclusion. On line at
http://www1.oecd.org/subject/poverty/products/
The Battle against Exclusion: Social Assistance in Belgium, the Czech
Republic, the Netherlands and Norway.
The Battle against Exclusion: Social Assistance in Australia,
Finland, Sweden and the United Kingdom.
The Battle against Exclusion: Social Assistance in Canada and
Switzerland.
Australia
Farrington, F. (2002). Social Exclusion in South Australia: Analysing
the South Australian Labor Party's Social Inclusion Initiative. Available
at http://www.ssn.flinders.edu.au/geog/2001honours/paper%203.doc
Australasian Housing Information Exchange contains a number of papers
concerned with social exclusion in Australia and elsewhere. Available at
http://www.housing.infoxchange.net.au/ahin/library/housing_policy/social_exclusion.shtml
Canada
Atlantic Centre of Excellence for Women's Health (2000), Social and
Economic Inclusion in Atlantic Canada, Atlantic Centre of Excellence for
Women's Health,, available at
http://www.medicine.dal.ca/acewh/inclusion-preface.htm.
Colman, R. (2001), Health Impacts of Social Exclusion in Atlantic
Canada. The Effect of Income, Poverty and Employment Patterns, Genuine
Progress Index Atlantic (GPI Atlantic), available at
http://www.gpiatlantic.org/pr_socialexclusion.shtml
Galabuzi, G. E. (July, 2004), Social exclusion in Raphael, D. (Ed.),
Social Determinants of Health: Canadian Perspectives, Canadian Scholars
Press., Toronto.
Guildford, J. (2000), Making the Case for Social and Economic
Inclusion, Population Public Health Branch Atlantic Region, Health Canada
(PPHB-Atlantic), available at
http://www.hc-sc.gc.ca/hppb/regions/atlantic/documents/social.pdf.
Labonte, R. (July, 2004), Social inclusion/exclusion and health:
Dancing the dialectic in Raphael, D. (Ed.), Social Determinants of Health:
Canadian Perspectives, Canadian Scholars Press. Toronto.
Noel, A. (2002), A law against poverty: Quebec's new approach to
combating poverty and social exclusion, Canadian Policy Research Networks -
Family Network: Ottawa, Canada.
Available at http://www.cprn.com/en/doc.cfm?doc=183
Population Public Health Branch, H. C., Atlantic Region, (2001), Key
Learnings from PPHB Atlantic's Work on Social and Economic Inclusion
1998-2000, Population Public Health Branch Atlantic Region, Health Canada
(PPHB Atlantic), available at
http://www.hc-sc.gc.ca/hppb/regions/atlantic/documents/pdf/key_learning_two_e.pdf
Finland
National Action Plan against Poverty and Social Exclusion for
2003-2005 (Working Group Memorandum (2003)
Mental Health and Social Inclusion (2001)
National Action Plan Against Poverty and Social Exclusion (Working
Group memorandum (2001)
Poverty and Social Exclusion in Finland in the 1990's (1999)
All available at
http://www.vn.fi/vn/stm/english/publicat/publications_fset.htm .
Holland
Sociale uitsluiting. Een conceptuele en empirische verkenning.
Sociaal en Cultureel Planbureau [Social and Cultural Planning Office of the
Netherlands.] Available at
http://www.scp.nl/boeken/werkdocumenten/doc99/nl/acrobat/default.htm
Norway
The Ministry of Social Affairs is responsible for issues of social
exclusion, at http://www.brussel-eu.mfa.no/EEA/Social+Affairs/Social.htm
Sweden
Sweden's action plan against poverty and social exclusion 2003-2005
at
http://europa.eu.int/comm/employment_social/news/2001/jun/napincl_03_sv_en.pdf
United Kingdom
Gordon, D., Levitas, R. and Pantazis, C. (2004). Poverty and social
exclusion in Britain: The Millennium Survey. Bristol, Policy Press. Also,
see other relevant Policy Press Publications at
http://www.bris.ac.uk/Publications/TPP/povfly.pdf
Iliffe, S. (1997), Britain Divided: the Growth of Social Exclusion in
the 1980s and 1990s (Book Review), BMJ, Vol. 315, No. 7105, pp. 437-438. On
line at http://www.bmj.com.
Rahman, M., Palmer, G., Kenway, P. and Howarth, C. (2000), Monitoring
poverty and social exclusion 2000, Joseph Rowntree Foundation: York, UK.
Social Exclusion Unit (2001), Preventing Social Exclusion, Social
Exclusion Unit: London. See other Unit publications at
http://www.socialexclusionunit.gov.uk
Walker, A. and Walker, C. (Eds.) (1997), Britain Divided: The Growth
of Social Exclusion in the 1980's and 1990's. Child Poverty Action Group,
London.
United States
Rainwater, L. and Smeeding, T. M. (2003), Poor Kids in a Rich
Country: America's Children in Comparative Perspective. Russell Sage
Foundation, New York.
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