Social Exclusion and Inclusion: A Primer

in #MedEd/Public Health by

This was a write-up I did for an assignment as part of my Residency training. We have such “informally formal” assignments which are assigned to us in course of the intra-departmental seminars. Now there may well be a lot of mistakes in this (it is supposed to be a primer for me actually!) so please be a little kind when taking this down. Hope you enjoy the read and do not find too many mistakes!

Social Inclusion and exclusion are socio-economic concepts that are used to define the idea of social disadvantage. Although the task of defining an abstract and culture-biased issue such as social exclusion or social inclusion is onerous, there have been efforts to characterize the nature of these terms in a broad manner. While tagging social exclusion has been easier, it has been more difficult to precisely define or characterize social inclusion. Thus, the accepted form of the latter is often as a reverse of social exclusion, and the truth remains that it is almost impossible to have a ceiling effect on the topic of inclusion. The room for improvement, they say, is the largest room around!

Social exclusion, on the other hand, has been characterized or defined in a number of ways. Starting from the broad terms like poverty, to more specific and culture-sensitive definitions, there have been a multitude of definitions that have been placed to characterize this concept. Simply put, social exclusion refers to the alienation of a certain group of people within a society to certain inalienable rights that are otherwise enjoyed by the other members of the same society. This can be expanded to define it in terms of multiple variables that affect the structure of a social class system, like castes, financial status, educational status, etc.

Social inclusion brings with it the concept of affirmative action that can change or modify the factors that lead to disenfranchisement of a section of the society leading them to suffer the outcomes of social exclusion. Now, to digress for a moment, I’d like to point out the interesting history behind the term “affirmative action”. It was first used in the United States (no surprise!) when President John F. Kennedy signed a declaration to promote actions to achieve non-discrimination. This set of activities was filed under the head of affirmative action.

However, for me, the definition of social inclusion is simpler. It has been explained by John Lennon in his epoch making song, Imagine:

Imagine no possessions
I wonder if you can
No need for greed or hunger
A brotherhood of man
Imagine all the people sharing all the world
You may say
I’m a dreamer, but I’m not the only one
I hope someday you’ll join us
And the world will live as one

If you love the song like I do, feel free to play it while reading the rest of the short note!

Coming back to the discussion, one has to keep in mind that social inclusion and exclusion cannot be viewed as separate entities, independent of the other. They are intertwined. In the blurb to their book, Bhattacharya, Sarkar and Kar have explained it succinctly:

Both exclusion and inclusion relate to the access to participation in the public realm, public goods and services for certain groups of people who are minorities, marginalized and deprived … While the problems of exclusion remain even in advanced Western countries in respect of the minorities of sorts, and the underprivileged, the problem of deep-rooted social and cultural exclusions is acute in post-colonial countries, including India.

Hence, we come to the concept that social inclusion and exclusion are along a continuum which have different factors modulating the rise and fall of societal cohorts through the different stages of this continuum.

However, one must also keep in mind that exclusive exclusion is also not a usual feature. More often than not, in life, the grey zone between the two extremes of black and white is where we tend to cluster. It is the same in the case of this concept as well. Certain schools of thoughts are of the opinion that the term of social exclusion is too unidimensionally damning to be of any practical importance. They propose the term adverse inclusion or adverse incorporation to signify the condition where there is inclusion, but under adverse terms. This is usually the result of the unequal power relations that create a gradient (e.g. economic) in the societal groups.

A similar line of argument can also be forwarded against the notion of social inclusion. In this case, the concept that is of more practical importance is social integration. Social integration is defined to be:

“the process of promoting the values, relations and institutions that enable all people to participate in social, economic and political life on the basis of equality of rights, equity and dignity” (1).

Most of the scholarly work coming out of the United States or the European countries have focused mainly on the fiscal side of the story. They have concentrated on the financial and power equations that have created social divides and have maintained the gradient. There have been some workers who have espoused the issues of sexual minorities as well, telling the story of their social exclusion. In India, the situation is more complex. A polyglot of cultural systems, each radically different from the others, in India, there are many more variables in the definition of social exclusion. Caste-based, religion-based, language-based, region-based, gender-based, age-based, even based on one’s political identity… the number of factors that can contribute to the social exclusion of a segment of people in India can be simply mind boggling. The history of India, as also the narrative of present-day India, is fraught with stories of horrific crimes against the minorities or the marginalized groups.

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In this respect, I believe that the concept of social exclusion is basically an outcome of power equations. Somewhat like the theory of “jiski laathi, uski bhaains”, if one can forgive the crude comparison!

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Considering the marginalization point of view, the concept of social exclusion is also governed quite a bit by the accepted norms of being normal. Anyone perceived to deviate from the accepted norms is thus bound to be marginalized and hence be subjected to social exclusion or adverse incorporation. This is particularly seen in issues of sexual minorities and such other sensitive issues.

Social exclusion is a dynamic concept. Since social exclusion is a construct largely based on what the society in question
considers to be the normal, it varies from country to country and even in the same country over different periods of time. Take the instance of Ireland, for example. In the light of the recent economic meltdown, in Ireland, like in many other countries, the meaning of social exclusion is getting re-invented. Ireland, which was in the middle of a financial boom powered by the credit and realty sectors, instituted a National Action Plan to end Poverty and Social Exclusion and their official white paper came out in 2005. However, in the wake of the recent debt-ridden state of the country these definitions have to undergo a re-interpretation. Perhaps Ireland is an extreme example considering that it has been hit by the double whammy of the global financial meltdown and a nation-wide banking scam (described to be one of the largest banking scams in the history of the world; so the Indian politicians can get envious now), but this is just to illustrate the fact that the cut-offs for defining social inclusion or exclusion are mobile and move in keeping with the financial well-being of the country or the specific society as a whole.

Moving in to the health systems side of exclusion, the disenfranchised people have identified five gaps contributing to the process of exclusion (2):

1. A structural gap, referring to discrepancies in terms of satisfaction of fundamental rights;

2. A participation gap, referring to inhibitors to genuine participation in society;

3. A feeling gap, referring to psychological and social traumas, shame and mistrust;

4. A knowledge gap, referring to limited knowledge on e.g. administrative regulations;

5. An aptitude gap, referring to deficient social end relational skills.

The Health Inc research project – Financing healthcare for Inclusion, Socially inclusive healthcare financing in West Africa and India – hypothesizes that an important cause for the limited success achieved through the recent health-financing reforms is the fact that there is extensive social exclusion at play at the interface between the targeted population, the health system and the context of the program. Basically, due to the evils of social exclusion, a large part of the targeted population is unable to reap the benefits of the healthcare system.

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Image credit and Health Inc info

In conclusion, Social exclusion is a dynamic concept that is getting newer dimensions added to it with the passage of time. This is more than just a sociological concept or a measure of economic disadvantage in a community. It is the gateway which affords a look into affirmative action in the form of changes that can be made or interventions that can be introduced to bring up the living standards of the population as a whole.

References:

1. UN Expert Group Meeting on Promoting Social Integration: Draft Summary, Finland, July 8-10 2008, p.2

2. Casman M-T, Vranken J, Dierckx D, Deflandre D, Campaert G (2010) Experts by experience in poverty and social exclusion: innovative players in the Belgian federal public services. Antwerp-Apeldoorn: Garant.

3. Wikipedia: http://en.wikipedia.org/wiki/Social_exclusion

4. Governance and Social Development Research Center: http://www.gsdrc.org/go/topic-guides/social-exclusion/definitions-and-different-understandings-of-social-exclusion#key debates

Skeptic Oslerphile, Scientist at the Indian Council of Medical Research, National Institute of Cholera and Enteric Diseases. Interests include: Emerging Infections, Public Health, Antimicrobial Resistance, One Health and Zoonoses, Diarrheal Diseases, Medical Education, Medical History, Open Access, Healthcare Social Media and Health2.0. Opinions are my own!

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