What are the limits of present empirical evidence over the links between health inequality and social exclusion? How does social exclusion contribute to the theories of social inequality in health? This Social Exclusion Knowledge Network paper examines the theoretical contribution that social exclusion can make to theories of social inequality in health. It is argued that the present focus on a state of social exclusion fails to recognise the crucial causal link to power inequalities across society. It does not take into account the potential for targeted inequality amongst marginalised groups.
The concept of social exclusion implies a focus on causes of poverty and inequality. An examination on causation and macro-micro linkages is central to the understanding of social inequalities in health. A commonality exists, alongside problems, when it comes to exploring the links between social exclusion and health inequalities:
- Social exclusion lacks a unified definition, rendering the quantifying and direction of a common relationship with health contentious. The issue becomes more problematic when considering the variety of proxy indicators used.
- Little empirical research exists focussing on the explicit relationship between social exclusion and health inequalities. Instead, research focuses on a particular dimension or groups, thus limiting the overall scope and conceptualising social exclusion as a ‘state’.
- Explanatory models all highlight the multi-factorial character of the pathways leading to health inequalities, and these are strongly social. Risks to health arising from the way societies are organised are therefore focused upon.
- Power embedded in social relationships, and exercised through both formal and informal institutions, is the fundamental driving force for health inequalities.
- The sole focus on a ‘state’ of social exclusion does not recognise the main causal links to inequalities in power across societies. Thus this approach cannot alone achieve the goals of greater equality and social cohesion.
Similarities do exist, such as over the abuse of power in social relationships impacting on health and well being. Other deprivations are caused such as low income, disease and ill-health. Therefore the power to restrict participation in economic, social, political and cultural relationships as a result of the abuse of power, leads to health inequalities.
Social exclusion can be integrated into health inequality frameworks, especially as a relational concept. This can be achieved through moving away from a sole focus on the state of social exclusion:
- Attention is required over the individual experience of inequality. Without this micro focus the explanations will tend to be deterministic and fail to realise the people involved are not just passive victims.
- The relational approach underpinning the World Health Organisation Commission on Social Determinants of Health (CSDH) framework should be considered in relation to macro-micro linkages. There is a requirement to integrate the people experiencing social and health inequality with those doing to excluding.
- A focus on relational exclusionary processes will force attention onto the causal role of social and economic inequality, driven by unequal power relationships.
- Two parallel and closely linked dimensions are required to reduce health inequalities: Action to address the generative processes embedded in social relationship; and support for full and genuine participation in identifying and acting on inequalities as well as the transformation of power relationships.
