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Pursuing health equity and social justice some issues from the perspecsocial exclusion, vulnerability and disadvantageHow should ‘we' understand it?
What should ‘we' do about it?
Professor Sociology and Public Health Lancaster University 1. How are the terms exclusion and vulnerability best defined to inform public health policy and practice for greater equity? 2. What should be the policy goal and mechanisms for change? 3. Which contemporary approaches to addressing exclusion and vulnerability are most likely to meet this goal? conditional welfare and choice Participative systems, empowerment and practical wisdom 4. Concluding comments
Typical contours of vulnerability in Europe
Irregular migrants: Citizens of Nowhere. amongst
>11% of adults in Europe are disabled,
the world's poorest and the most disenfranchised.
oppressed and disadvantaged by
prejudiced beliefs and actions (disablism).
Roma – amongst millions of people globally, some of whom
describe themselves as Indigenous, experience racism and
Unequal places – millions of people
oppression, their cultures devalued and undermined.
across Europe are living and growing
old in marginalised places
Reflects a shopping list approach
Exclusion and vulnerability as ‘states of being'
These words typically used to describe ‘states'experienced by particular groups of people e.g. Roma, migrants, displaced people, people with mental health problems, etc.
These groups are excluded from adequate living
standards, decent homes, credit, health care,
education, political rights, dignity, family life, etc.
They are therefore vulnerable to future ‘shocks' and chronic
Vulnerability as a state of ‘being'
• Resulting from individual characteristics, bad luck or poor • ‘Context' may be recognised - people are vulnerable due to unequal access to resources/assets – but often seen as passive ‘victims' of this context • Increasingly they may be seen as bundles of assets to be exploited to encourage ‘self care' and behaviour change • Research suggests that vulnerable ‘states' do not fully explain health disadvantage Exclusion as process and relational
- Exclusion comprises of dynamic, multi-dimensional processes driven by unequal power relationships - These processes operate and interact: - across four dimensions - economic, political, social and cultural- And at different levels including individual, household, group, community, city, national and global levels. - They create a continuum of inclusion/exclusion characterised by inequalities in the resources and rights required to release capabilities Vulnerability as spatial & relational
• Social spaces are characterised by vulnerability not • These vulnerable social spaces are "created, perpetuated or exacerbated by those living in safer more affluent spaces" • People forced to live in ‘vulnerable spaces' are active – they develop logical coping strategies based on diverse capabilities including ‘practical wisdom' (Lewis & Kelman, 2010:194) Meanings Shape Action.
Focus on ‘states of being'
• Direct policy and practice attention to individuals and their deficits
• Label and stigmatise disadvantaged individuals/groups
• May treat them as passive victims of their context - to be done to
• Dichotomises: them and us/ in or out – makes unequal inclusion invisible
Focus on exclusionary processes and vulnerable social spaces shifts
the policy lens onto:
• Relationships between exclusion, vulnerability and drivers of inequality Interactions between different dimensions of inequality: social, economic, political, cultural rather than a single typically behavioural foci • Barriers preventing the release of individual and collective capabilities 2. What should be the policy goal and mechanisms for change? 3. Which contemporary approaches to addressing exclusion and vulnerability are most likely to meet this goal? conditional welfare and choice Participative systems, empowerment and practical wisdom
Social Justice: a policy goal?
Addressing social determinants of healthis "a matter of social justice" and an"ethical imperative" Injustice is killing people on a grand scale.
(Marmot review 2009)
"The challenge is to work out the precise demands of
justice that are.practically useful.
Behavioural and health outcomes do not provide an ethical or sustainable basis for policies promoting social justice An Aristotelian framework does because it prioritises human
flourishing as the goal and capability release as the means.
According to this framework justice demands policies that: support the release of individual/collective capabilitiesRemove barriers to people's ability to achieve their freedom to exercise reasoned agency on the basis of their ‘practical wisdom' Make wise use of limited resources – are effective Consider three policy approaches from a
1. Conditional welfare 3. Participation and empowerment 1. Conditional welfare
1st wave : low/middle income countries poverty reduction – Transfer cash typically to mothers in poor households– On conditions that they invest in children's human capital e. g: • Attendance at antenatal clinics and/or parenting classes• Monitoring of children's development and immunisation• Enrolling children in school and ensuring attendance 2nd wave: Spread to high income countries – Cash or services on condition that behaviour changes– More diversity : employment to smoking cessation
Conditional welfare 1997
Many places in UK
Many places in USA
Northern territory and Western Australia elfare ditional welfare
programmes 200 199
Low-income pregnant women, US Antenatal clinic $5 gift certificate and entry into $100 raffle Middle-income patients, US Return appointments Free or reduced cost appointment African-Americans with depression, US Attend appointments $10 per appointment Medication adherence
Active drug users, US
Return appointment for tuberculosis test results Homeless patients, US Return appointment for tuberculosis treatment Low-income patients Take-up flu and childhood immunisation Lottery for groceryvouchers of $50 or $25 to $100 Low-income women Enrol in mammography screening $10 incentive if enrolled within a year $5 grocery coupon Smoking cessation
Smoking cessation Salary bonus for not smoking at work Smoking cessation money withheld from paycheck returned if goal met Diet
Overweight adults, US
Free pre-packaged meals or financial incentive max $25 week. Deposit $200 -return $20 per week if attend meetings, met calorie restriction goal or met weight-loss goal. Smoking
Quit and win lottery-style competitions Quit and win lottery-style competitions cash or holiday prizes Exercise
Obese patients, US
Increase physical activity Financial incentive of $1–$3 per walk plus personal training Low-income patients, UK Increase physical activity Motivational interviews and leisure centre vouchers Sexual health
Teenage mothers, US
peer-support to prevent repeat pregnancies STI patients, US Attend 4 risk-counselling sessions $15 or voucher of equivalent value Drug cessation
Abstain from drug use Retail vouchers with therapy and living skills US Cocaine users, US Abstain from drug use Three Key Questions
• Do conditional welfare programmes work better than unconditional ones? • Do they have any adverse effects? • Are they compatible with a capability approach to increasing social justice? Does behavioural conditionality work?
Conditional cash transfers have been associated with:
Reduction in child poverty and increased household income Improved nutrition and child growth Increased attendance at clinics & immunisation rates Increased school registration and attendance Decrease in child labour Increase hepatitis vaccination of intravenous drug users Increase uptake of TB programmes Increased smoking cessation rates But the picture is complicated.
Largest impact on use of services – process indicators Mixed evidence of impact on ‘final' outcomes e.g. more years of school but attainment not improved and wages not Less effective at changing complex behaviours e.g. smoking Differential social impact e.g rates of smoking cessation smaller in low income groups Policing compliance associated with high administrative costs Experience can be stigmatising and dispiriting The conditionality may not be necessary
Universal child benefits in UK were associated with: • Reduction in child poverty• Women spending money on food, children's clothes & school fees Universal free primary education in Botswana resulted in: • attendance rates increasing to 84% • Gender parity at primary school level Rural Ecuador unconditional cash transfers associated with • Positive physical, cognitive, and socio-emotional outcomes• significantly better outcomes for poorest children And conditionality won't release
Economic coercion contradicts the ethical demands of social justice - freedom to choose is central to a socially just society "Whilst functioning should be held in view by governments, capability is the political goal – policies must respect humans' ability for practical reasoning and choice .once capabilities are assured people must be free to make choices" (Nussbaum) The 20th Century Legacy
• In UK Beveridge identified 5 giants on the post-war "road to : want, disease, ignorance, squalor, and idleness – evidence around the globe.
• The response in many countries - universal systems paid through taxation/social insurance but free at point of use forsocial security, health care, education and public housing -unprecedented improvements in living standards and health.
• Surely our response to the 21st century giants of inequality should be more imaginative than meagre stigmatisingconditional welfare and marketisation of services supported bylimited evidence "The task is not just to re-introduce a successful historical model. It is to re-shape that model to meet new problems as well as problems that have been familiar for generations. The strength of a universalistic approach.is in building coalitions between groups in society. Social cohesion Shrewdly interpreted, universalism can encompass rights by
gender, race, ethnicity, age and disability and give nationalism
a stronger edge both in negotiating with outside powers and
withstanding international shocks". (Townsend, 2007, pp1)
3. Participation and empowerment – another
A selection of English policy statements.
• ‘empowering citizens to express views on
how needs are met'.
• ‘working with local people to strengthen
• ‘bringing local people into the service
• ‘putting active citizens at the heart of
tackling social problems'
• ‘Building people's skills, knowledge, abilities
and confidence to take action and play
leading roles in developing communities'
• Nothing about us without us! Consumers
The health potential of empowerment
• Study of Indigenous suicide in British Columbia – Significantly elevated suicide rates (5 time across the province, – But not uniformly distributed across 1st Nation groups: – Aboriginality per se is not a risk factor. • „Cultural continuity‟ explained different risks • But measures reflect degree of „empowerment‟ – history and success of land claims; – self government; – control of services; – Dedicated cultural facilities Personal persistence, identity development and suicide, Chandler, Lalonde, Sokol, Hallett, Monogr.Soc.Res.Child.Dev. 2003:68(2) Decreasing suicide rates with increasing
People can contribute practical wisdom when they participate in decision making systems Practical wisdom is the complex responsiveness of ordinary people to the concrete situations the experience in their everyday lives (Aristotle) Practical wisdom can reframe public health problems:
„Official‟ knowledge and practical wisdom may involve different assessment of risk Professional: ‘There is a general perception that cars are travelling faster than they are…If you look at the roads. they‟re not really that dangerous‟ Parent:: ‘There are too many cars… is it dangerous for the children, because they go between the motors to see if another motor is coming‟.
Participation builds evidence: "Really interesting question about
child accidents is that given all the dangers, how do so many
people manage to keep their children safe in unsafe
environments? (Helen Roberts, 1997)
Lay theories about the causes of poor health
Stress of poor living conditions But strength of character
a major cause of ill health
protective in some circumstances It's obvious that we would
"The first thing you do
not feel health wise as
when you get up is see the
someone would who has all
graffiti, the vandalism and it
the comforts and luxuries.
doesn‟t help. But at the end of
They go on holidays three
times a year…. we can'
the day it‟s how the individual
deals with it all. If you let it
afford one holiday. Their
get you down, you are going to
outlook on life is more
have the health problems
relaxed comfortable. We are
struggling day to day with
pressures and to keep up with
However, wider determinants are not within their "I mean everybody has a bit of worry. but outside
worries that you haven‟t got any influence on changing
that has a bigger effect on you I think like not having a
job or no money. You can‟t sit down and think „well
I‟ve got this problem and how can I solve it‟. Cos you
haven‟t the power to change it …."
So they develop ways of coping with these risks to health which ironically contribute to health inequalities Behaviours or "coping strategies'?
• Privatisation of everyday life: people keep to their own social
space to protect themselves for antisocial behaviours but contributes to loneliness and isolation • Social distancing from ‘difficult people‟ protects positive
identity but undermines social cohesion and collective action for change • Socially valued identities pursued as pathway to inclusion e.g.
teenage motherhood, some antisocial behaviours • Health damaging behaviours develop [or can‟t be changed]
The doctor put me on Prozac for living here because it's depressing. You look around and all you see is junkies. I started drinking a hell of a lot more since I've been here. I drink every night just to get to sleep. I smoke more as well. There's a lot of things The purpose of practical wisdom about
Reconstructs moral worth"To acknowledge inequality would be to admit an inferior moral status foroneself and one's peers: hence perhaps the emphasis on ‘not giving in' toillness. This can be seen to be a claim to moral equality even in the face ofclear economic" inequality Mildred Blaxter, 1997, 754 Re-asserts individual controlEmphasises indirect rather than direct mechanisms particularly emphasis onstress as a key factor mediating relationship between material circumstancesand ill health. Stress could be in people ' s control in way thatstructural/material inequalities can not Reconciles individual need for control with recognition of widerdeterminants – no lack of knowledge The politics of practical wisdom: Fish Head Soup
Recognising lay expertise in disadvantaged communities
Concluding comments Some possible pathways for public health in relation to vulnerability cross-sectoral working ….
The Pursuit of Social Justice –
Conditional welfare or Capability Release?
• Assumes poor people are irresponsible without reasoned agency
• ‘Naming and shaming' – uses stigma as informal social control
• Economic coercion – uses cash to manipulate behaviour
• Improves ‘functioning' but may increase inequalities and reduce
social cohesion; neglects capability release and human agency Not compatible with the pursuit of social justice Universalism, participation and utilisation of practical wisdom
• Promotes ‘sense of control' and capability release
• Underpinned by trust, shared identity and common purpose
• Strengthens social networks increasing social cohesion
• Practical wisdom of people based on experience can produce
effective policies and services valued and used by communities Recognise the fault lines between practical wisdom and professional understandings • Practical wisdom connects experience and behaviour with material and social context and presents health damaging behaviour as coping strategies • Professionals/researchers fragment people‟s experience into individual or clusters of behaviours and/or lifestyle often presented as „freely chosen‟ • Practical wisdom reflects realistic assessments of limited opportunities for control where professionals may see fatalism, low locus of control or health „illiteracy‟ • Lay people and professionals may share „values‟ but interpret implications for action differently e.g. – Both accept parental responsibility for child safety but professionals emphasise their educational role, parents‟ emphasise responsibility of many agencies people Professionals should reframe accounts and images of vulnerability and health inequalities to reduce stigmatisation The Guardian
Scottish Government's Close call on health Tackling in areas with the worst
health inequalities pilot nears end Health and deprivation
NHS Slow to tackle inequalities and tackling health Sustainable Development
Commission the key to tackling health Put the public back into public health
Absence of people as • individuals dominate public „knowing subjects‟ using health but as accumulations practical wisdom to make decisions • of risks, vulnerabilities and that are logical resiliencies or sets of freely chosen behaviours In context of their lives Acknowledge potentially conflicting expectations of participation with lay people….
• For politicians: a technology of legitimacy? (Harrison and Mort)
• For managers: a mechanism to improve efficiency?
• For service providers: sharing power and responsibility, co-production
• For „disadvantaged people‟- a „struggle over meaning‟
Health is not bought by the chemist's pill Nor saved by the surgeon's knife Health is not only the absence of ills But the fight for the fullness of life In summary
Important to include people labelled as excluded and/or vulnerable in cross-sectoral working – civil society as partner doesn‟t mean only NGOs Professionals initiating action with disadvantaged groups may benefit from health literacy training to enable them to: – Reframe the issues and their representation in less stigmatising ways – Understand the social purpose of people‟s practical wisdom about their lives and actions – Act on barriers within professional groups and organisations that undermine genuine engagement across sectors Create new knowledge spaces that promote shared understandings of the the drivers of vulnerability and health inequalities and co-produce solutions i.e. – Support enduring conversations not one off consultations – Engage people in agenda settings, reframing problems and co-producing solutions– Be organised in ways that ensure inclusivity – Address the power imbalance between different understandings of health -different „types‟ of knowledge. May need mediation.
Literature & medicine Literature and medicine: narratives of mental illness Anne Hudson Jones Autobiographical accounts of mental illness have for illness as demon possession continued to appear in the 18th centuries provided a fascinating window on the world of and early 19th centuries,10–13 even as cultural beliefs about the madness for those fortunate enough never to have sojourned