If I asked you to identify vulnerable populations – both within Australia and globally – most well trained Croakey readers could probably come up with a decent list.
We post a lot about the social determinants of health and rightly so. Issues such as financial stress, insecure housing, and limited access to education, employment, nutritious food and basic healthcare make people and populations who are subject to these hardships much more vulnerable than others to ill health and early death.
And as inequality within and between populations around the world is increasingly being recognised as the biggest threat to global health and security, the question of how to reach out to vulnerable groups is firmly on the agenda.
The theme of an international conference being held in Bangkok this week is, Addressing the Health of Vulnerable Populations for an Inclusive Society.
Inclusion is another thing we talk a lot about – making health, social and other services inclusive so that vulnerable groups can access them. But as Professor Fran Baum from Flinders University’s Southgate Institute for Health, Society and Equity, explains below, on the path to inclusion, it is well worth stopping off to discover what societal structures have caused people to become excluded in the first place, and to change the things that are keeping them there.
Fran Baum is attending the conference and is also Chair of the People’s Health Movement Advisory Council, from whose meeting this post is drawn. The conference is ongoing: you can follow using the hashtag, #pmac2017.
Professor Fran Baum writes:
The Prince Mahidol Award Conference is being held in Bangkok this week. The conference, which focuses policy-related public health issues of global significance, is hosted annually by the Prince Mahidol Award Foundation, the Royal Thai Government and other global partners, for example the World Health Organization, the World Bank, and the Rockefeller Foundation. The theme for his year’s conference is “Addressing the health of vulnerable populations for an inclusive Society”.
The People’s Health Movement is also a partner and, in addition to attending the main conference, each year we organise to hold a side meeting of our Global Steering Council. As a response to the theme of the main conference, this year’s side meeting (30th January) was on “Social inclusion for Health for All: The imperatives of civil society engagement”.
The meeting stressed the importance of social inclusion in achieving health for all. We examined the political economy of social exclusion and defined five societal processes that produce exclusion:
- The historical legacy of colonialism, which results in the exclusion of Black Americans and Indigenous peoples from education, employment, and housing; and the deprivation of freedom through slavery in the US, the Stolen Generations in Australia and residential schools in Canada, and high imprisonment rates in many countries for minority populations.
- The dominant neo-liberal macro-economic environment which privileges the needs of corporations over those of people and the environment. Under these conditions, trade agreements, tax regimes, and regulations are reshaped and constructed to support business interests.
- The inequities that have resulted from the processes under points one and two are rapidly becoming more extreme. For example Oxfam has recently estimated that just eight men now own the same amount of wealth as the poorest half of the world’s population. The incomes of the poorest 10% of people increased by less than $3 a year between 1988 and 2011, while the incomes of the richest 1% increased 182 times as much. The result of these inequities is that more and more people are excluded from the economic, and so the social, benefits of society. The concentration of personal wealth means there is less funding for public services and facilities that are needed to facilitate the inclusion of people in the benefits of education and health care.
- Patriarchal decision making structures are an important means by which women are excluded from their rights. This was clearly illustrated by the much tweeted image of President Trump signing the Executive order (Global Gag Rule) which bans the provision of US funding to international NGOs that provide abortion services, or offer information about abortions. The photograph showed eight older white males with no women present. Such structures exclude women from realising their economic, social sexual and reproductive rights.
- Political exploitation of fear of difference operates to exclude and marginalise groups, and so has a markedly adverse effect on their health. This is illustrated most strikingly in the current global environment for refugees and asylum seekers. In Australia the policy of off-shore detention has been shown to have severe mental health impacts, and as we were meeting the Trump administration’s banning of passport holders from seven countries from entering the US (and the suspension of refugee arrivals) was having an immediate impact on people’s well-being in multiple ways. The political exploitation may be terrifying to those directly affected (for example not being able to reunite with family members and fear of further persecution) and also to the wider community who fear that political exclusion may soon be expanded to include new groups, and are distressed by the treatment of those who have sought asylum in their country.
Changing the structures
Given the dominance of such exclusionary processes, the focus of the People’s Health Movement is on changing the structures that maintain and support these processes. Our meeting presented details of an on-going action research project which is examining the ways in which healthy civil society operates to achieve health for all.
We examined the importance of articulating a clear theory of change, which links actions and strategies to the aim of influencing structures rather than focusing on the behaviours and actions of the people who are the victims of colonialism, neo-liberal or patriarchal structures.
A powerful case study
By way of a powerful case study of how this can happen, Anele Yawa gave a presentation on the Treatment Action Campaign (TAC) in South Africa. Yawa, who is General Secretary of the TAC, showed how the campaign started to address the exclusion of people with HIV/AIDS from effective treatment because of the cost demanded by Big Pharma.
TAC created a mass movement of people directly affected by HIV/AIDS and the movement was highly successful in lowering the cost of drugs and including those previously excluded from treatment.
Their work now also includes reducing discrimination and ensuring that groups such as sex workers can gain access to treatment. Now TAC is looking more broadly at how health systems may exclude people from access and how the mass movement it has created can be mobilised to think more broadly about health services and the social determinants of health.
Eliminating exclusion, embracing inclusion
Throughout the The Prince Mahidol Award Conference members of the People’s Health Movement will be reminding delegates that social inclusion will only be achieved when the exclusionary processes we have identified change to be more inclusive and healthier.
As David Sanders (Co-Chair PHM Global Steering Council) summarised “We should not limit the struggle to the obvious problem but go to the causes of the causes,”
*Fran Baum is a Matthew Flinders Distinguished Professor of Public Health and Director of the Southgate Institute of Health, Society and Equity at Flinders University. She is the Chair of the People’s Health Movement Advisory Council and a member of the Global Steering Council. On twitter @ . To follow the conference #pmac2017