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Social Inclusion

Background: Social inclusion concerns people's basic needs as well as their ability to participate fully in society. In some ways, it encompasses all of the societal and economic conditions - and inequities - that underlie our health: our neighborhood, income, job, opportunities, support network, and other resources. But it also includes a political dimension because it relates to people's involvement in decision-making processes and their access to power and institutions.

The opposite of social inclusion is social exclusion, which can result from racism, discrimination, stigmatization and hostility as well as structural disparities and neglect. When individuals are made to feel less valued or have no control over their work and living conditions, they not only experience increased stress and anxiety but they feel disempowered, contributing to riskier behaviors and abuse, job and income instability, domestic strife, and isolation. Those consequences can in turn lead to higher social costs in terms of health care, welfare, crime, and lost productivity.

Social exclusion is tied to material conditions as well. When people are denied jobs or home loans; when they don't have access to decent, affordable housing, a good education, or reliable transportation; when their income is insufficient; when they lack opportunities to engage in civic life and can't gain access to other resources vital to their prosperity - all of these increase their likelihood of disease and premature death. For especially vulnerable populations like children, the effects can have a life-long impact even after their conditions improve - what experts like Dr. Jack Shonkoff have termed the "pile up" of risk or disadvantage.

Unlike absolute indicators, social inclusion or exclusion is measured in terms of relative advantage or deprivation within a society. Context matters - after all, the difference between living well or poorly on $1,200 per month depends on the society in which you live. Obviously hunger and homelessness exist even in wealthy nations like the U.S., but relative poverty, for example, gives us a broader picture of basic necessities, including: the ability to fix or replace something that breaks; money for school trips, convenience items and special occasions; good credit; insurance and protections in case of emergency; and collateral for home, car and educational loans.

Relative poverty has a powerful effect on health: People with higher incomes not only live longer, they are healthier. Children in poor families are seven times as likely to be in poor or fair health as children in the highest-income families, and lower-income adults are more likely to smoke, be obese, have diabetes and have heart disease.

Another important component of social inclusion is social support. Today, one in four Americans say they have no one to talk with about important matters - a number that has tripled in the last 20 years. The problem is not individual, it's structural. We work more hours annually than almost every country in the world, even Japan, and we spend on average 50 minutes a day commuting. It's no wonder that many of us are not spending enough time with our families, have cut back on volunteering and outside activities, and feel alone. Isolation is deadly, as researcher Lisa Berkman has shown, increasing the risk of nearly every cause of death.

Strengthening family ties and personal connections is certainly important to improve health. But that's only one piece of the puzzle, because the societal factors that most influence inclusion or exclusion are beyond an individual's control. Investing in our neighborhoods and schools; providing secure jobs with career ladders, good benefits and adequate income; improving work conditions; enforcing civil rights laws; supporting families and children; and above all, creating a society that works for everyone - these are the ingredients for a more inclusive, healthier nation.

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Image Thumbnail Reducing Health Disparities For Latino Immigrants By Strengthening Communities (pdf) E-mail to a friend
REPORT from PolicyLink and the Joint Center for Political and Economic Studies, Washington, DC, May 2004

This brief examines the ways in which the social, economic, and physical environments of Latino immigrant communities affect health and contribute to health disparities. The first part discusses the health of Latino immigrants in general and how health status is influenced by community factors related to immigrant status. The next part describes key immigration trends and explores some of the defining characteristics of this population, including issues unique to immigrant communities, such as language, legal status, settlement patterns, and community development issues. The third part discusses the importance of community approaches to immigrant health and describes several successful community efforts that build on the assets of Latino immigrant communities in order to improve health. Finally, we offer a number of policy recommendations designed to improve health and reduce disparities for Latino immigrants by strengthening the communities in which they live.

Image Thumbnail Reducing Health Disparities Initiative E-mail to a friend
WEBSITE by Contra Costa Health Services

CCHS has a department-wide goal to reduce health disparities by addressing issues of diversity and linguistic and cultural competence. Their site contains community health indicators for Contra Costa County, information on the county's five-year plan, and promising practices for cultural competence.

Image Thumbnail Reducing Racial and Social Inequalities in Health: The Need for a New Approach E-mail to a friend
SCHOLARLY ARTICLE by S. Leonard Syme, Health Affairs 2008

It is well known that people in racial and ethnic minority groups and in lower social-class positions have higher morbidity and mortality rates from virtually every disease. To effectively deal with the problem, we will need to adopt a more appropriate conceptual model that focuses on the fundamental determinants of health, we will need to understand how important this is for all Americans as a society, and we will need to better deal with the issues people care about: their children, homes, jobs, safety, education, families, retirement, and future prospects.

Abstract only. Subscription required to read full text.

Image Thumbnail Ron Sims: The King County Equity and Social Justice Initiative E-mail to a friend
TRANSCRIPT of a speech by Rom Sims, King County Executive, March 2008

In a speech for the CDC Health Transformation Lecture Series, Mr. Sims explains how his office has made health equity central to its work - across sectors and in partnership with communities, business, and local agencies - and makes the case for the CDC to use its considerable influence and reach to promote and support health equity nationally.

Image Thumbnail Running from Despair E-mail to a friend
NEWS ARTICLE by Joe Spring, New York Times, February 16, 2008

A positive look at how some young people living on reservations are becoming involved in cross country running. Wings of America, a team of Native American athletes from around the country that has won 20 national titles since 1988, is also an NGO that works to counter the high rates of diabetes, obesity, alcoholism, and suicidal depression on reservations.

Image Thumbnail Sir Michael Marmot Interview (mp3) E-mail to a friend
PODCAST, Web-exclusive content from UNNATURAL CAUSES

In this audio podcast, excerpted from an interview conducted during the making of UNNATURAL CAUSES, Sir Michael Marmot of University College, London, discusses the social gradient in health, his pioneering Whitehall Studies and why he's optimistic about improving health outcomes.


Image Thumbnail Social determinants of health: the community as an empowered partner E-mail to a friend
ARTICLE by S. Leonard Syme, Preventing Chronic Disease, January 2004

"While we in public health know the importance of involving community partners in our programs, we also know how difficult it is to do. The challenge of involving the community is especially difficult if one has been trained, as I have been trained, to be an arrogant, elitist prima donna. I am the "expert," after all, and I help people by sharing my expertise..."

Image Thumbnail Social Exclusion Knowledge Network E-mail to a friend
WEB SITE by the WHO Commission on the Social Determinants of Health

This Knowledge Network (KN) examines the relational processes that lead to the exclusion of particular groups of people from engaging fully in community/social life. These processes may operate at: the macro-level (access to affordable education, equal employment opportunity legislation, cultural and gender norms), and/or the micro-levels (income, occupational status, social networks - around race, gender, religion). The network also examines the linkages between social exclusion and proximal concepts such as social capital, networks and integration.

Image Thumbnail Social Injustice and Public Health E-mail to a friend
BOOK edited by Barry S. Levy and Victor W. Sidel, 2005

Edited by two past presidents of the American Public Health Association, with chapters written by 48 experts in various aspects of social injustice, this book addresses many aspects of social injustice and their relationship to public health. Social injustice manifests in many ways ranging from various forms of overt discrimination to the wide gaps between the "haves" and the "have-nots" within a country or between richer and poorer countries. It increases the prevalence of risk factors and hazardous exposures, which in turn lead to higher rates of disease, injury, disability, and premature death. This book is organized so that health professionals, students in the health professions, and others will find it of practical value in public health and medical practice, research, education, policy development, and advocacy.

Image Thumbnail Social Isolation in America: Changes in Core Discussion Networks over Two Decades E-mail to a friend
SCHOLARLY ARTICLE by McPherson, Smith-Lovin, and Brashears, American Sociological Review, June 2006

Have the core discussion networks of Americans changed in the past two decades? This study shows that between 1985 and 2004, the number of people saying there is no one with whom they discuss important matters nearly tripled. The mean number of "confidants" decreased by about a third (one confidant), and the modal respondent now reports having no confidant, whereas the modal respondent in1985 had three confidants. Though the data may overestimate the number of social isolates, these shrinking networks do reflect an important social change in America.

Image Thumbnail Staying Alive: Critical Perspectives on Health, Illness, and Health Care E-mail to a friend
BOOK by Dennis Raphael, Toba Bryant, and Marcia Rioux, 2006

In addition to the traditional approaches of health sciences and the sociology of health, this contributed volume shows the impact that human rights issues and political economy have on health, and takes up these issues as they occur in Canada and the United States within a wider international context. The book also contains chapters on issues of pharmaceutical policy, social exclusion, gender and care, the social construction of illness and disability, and approaches to promoting population health that include insights into the impact of economic forces such as globalization and privatization on health care and other health issues.

Image Thumbnail Strategic Review of Health Inequalities in England Post 2010 E-mail to a friend

Professor Sir Michael Marmot has been asked by the British government to Chair an independent Review to propose the most effective strategies for reducing health inequalities in England from 2010. This review is a response to the recommendation of the WHO Commission on Social Determinants of Health that national governments develop and implement strategies and policies suited to their particular national context aimed at improving health equity.

Image Thumbnail Tackling Health Inequities Through Public Health Practice: Theory to Action E-mail to a friend
BOOK edited by Richard Hofrichter and Rajiv Bhatia

Social justice has always been a core value driving public health. Today, much of the etiology of avoidable disease is rooted in inequitable social conditions brought on by disparities in wealth and power and reproduced through ongoing forms of oppression, exploitation, and marginalization.

Tackling Health Inequities raises questions and provides a starting point for health practitioners ready to reorient public health practice to address the fundamental causes of health inequities. This reorientation involves restructuring the organization, culture and daily work of public health. Tackling Health Inequities is meant to inspire readers to imagine or envision public health practice and their role in ways that question contemporary thinking and assumptions, as emerging trends, social conditions, and policies generate increasing inequities in health.

Image Thumbnail The Politics of Population Health E-mail to a friend
VIDEO PRESENTATION, Dennis Raphael, York University, January 20, 2006

This 45 minute lecture attempts to answer the question of why so little is done to address the social determinants of health when so much is known of their importance. Raphael posits that this inaction is largely due to the fact that the social determinants of health are themselves determined by policy decisions, and explores the politics behind these decisions.

Image Thumbnail The Poor Get Diabetes, the Rich Get Local and Organic E-mail to a friend
ARTICLE by Mark Winne

In this excerpt from his new book, Closing the Food Gap: Resetting the Table in the Land of Plenty, Mark Winne explains a growing split in the diets of the haves and have-nots; at the same time that the wealthy are coming to prefer organic and locally-grown foods, the poor have been losing geographical and economic access to healthy options. He also reports on a survey by the non-profit group Hartford Food System, which found that low-income consumers in the area would prefer to purchase organics and fresh foods, but simply couldn't access or afford them.

Image Thumbnail The Praxis Project E-mail to a friend

The Praxis Project is a national, nonprofit organization that builds partnerships with local groups to influence policymaking to address the underlying, systemic causes of community problems. Committed to closing the health gap facing communities of color, they forge alliances for building healthy communities. Praxis trains its partner organizations and provides research, technical assistance and financial support to tackle issues impacting the well being of communities. Their site contains an information resource center with additional resources and reports on equity and social justice.

Image Thumbnail THRIVE: The Tool for Health and Resilience in Vulnerable Environments E-mail to a friend

THRIVE is a tool developed by the Prevention Institute to help you understand and prioritize the factors within your own community that can help improve health and safety. The tool can help answer questions such as: How can I identify key factors in my community and rate their importance? How are these factors related to health outcomes? What can I do to address each factor? Where can I go for more information?

Image Thumbnail Tohono O'odham Community Action (TOCA) E-mail to a friend

TOCA is a community- based organization dedicated to creating cultural revitalization, community health and sustainable development on the Tohono O'odham Nation. TOCA was founded in 1996 as a non-profit organization. TOCA has adopted principles that represent our approach to community development and guide our programs.

Image Thumbnail Tohono O'odham Community Action (TOCA) - Cultural Renewal to Improve Health E-mail to a friend

Terrol Dew Johnson, featured in the "Bad Sugar" segment of UNNATURAL CAUSES, is co-founder of TOCA, a community-based organization focused on cultural renewal as key to empowerment and better health. TOCA has four primary program areas: basketweaving, traditional foods, youth/elder outreach and traditional arts and culture. www.tocaonline.org

Image Thumbnail Unequal health outcomes in the United States (PDF) E-mail to a friend
REPORT from the CERD Working Group on Health and Environmental Health, 2008

This report to the U.N. Committee on the Elimination of Racial Discrimination makes clear that racial discrimination in health care access and treatment is a human rights violation that deserves serious attention from both the CERD Committee and policymakers in the United States. This report was written by a coalition of experts in the fields of health policy and environmental justice, including academics and members of civil society organizations working to advance the right to health and the right to a healthy environment in the United States

Image Thumbnail Wealth Equals Health E-mail to a friend
VIDEO EXCERPT, Unnatural Causes - Episode 3

Wealth and health are tightly linked in the United States. As immigrants remain in the country, as they "become American," their socioeconomic status becomes increasingly relevant to their health status. For those who experience discrimination, low wages, unstable employment, and other stressors, this relationship may erode the health advantage they enjoyed upon arrival in the country.

Image Thumbnail What Is Health Equity? (pdf) E-mail to a friend

A one-page handout, excerpted from the UNNATURAL CAUSES Action Toolkit, providing a quick introduction to the concept of "health equity," and how to rephrase conventional questions about health into an equity framework.

Image Thumbnail What We Mean by Social Determinants of Health E-mail to a friend
SCHOLARLY ARTICLE, Vicente Navarro, International Journal of Health Services,

This article analyzes the changes in health conditions and quality of life in the populations of developed and developing countries over the past 30 years, resulting from neoliberal policies. The article concludes with a critical analysis of the WHO report on social determinants of health, applauding its analysis and many of its recommendations, but faulting it for ignoring the power relations that shape these social determinants. It is not inequalities that kill people, as the report states; it is those who are responsible for these inequalities that kill people.

Image Thumbnail Why Justice is Good for Our Health: The Social Determinants of Health Inequalities E-mail to a friend
SCHOLARLY ARTICLE by Daniels , Kennedy , and Kawachi, Daedalus, 1999

This article considers questions such as: "Is every health inequality that results from unequally distributed social goods unjust? If there is an irreducible health gradient across socioeconomic groups, does that make the very existence of those inequalities unjust? Alternatively, are some health inequalities the result of acceptable trade-offs?" 

A subscription is required to read this article online.

Image Thumbnail Why Our Greatest Health Concern Isn't Diet or Exercise - It's Neighborhood E-mail to a friend
OP-ED by Larry Adelman on AlterNet.org, February 19, 2009

Series Creator and Executive Producer Larry Adelman expands upon economist Robert Evan's analogy of health care as a repair shop to illustrate the crucial role that "road conditions" play in determining our health status.

Download as PDF.

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