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Society's excluded people ten times more likely to die early

People excluded from mainstream society in high-income countries have a tenfold increased risk of early death, according to research published in The Lancet.

Researchers found the mortality rate among socially excluded groups including homeless people, people who sell sex, prisoners and people who use hard drugs, was nearly eight times higher than the population average for men; and nearly 12 times for women.

By comparison, mortality rates for 15–64 year olds living in the poorest areas of England and Wales are 2.8 times the rate of those living in the richest areas for men and 2.1 times the rate for women.

Two papers highlight the extreme rates of death and disease faced by excluded people and lay out clear evidence for interventions that can help save lives and prevent people from finding themselves in such desperate situations.  

The first paper (Aldridge et al) shows that excluded people are more likely to be murdered or take their own life, but also more likely to die from accidents, overdoses, infectious diseases, cancers, liver disease, heart problems and respiratory diseases. In total, researchers analysed data from 38 countries with the UK, USA, Sweden, Australia and Canada providing the highest amount of data.

The lead author of the first paper, Dr Robert Aldridge from the UCL Institute of Health Informatics said: “We know that excluded populations suffer from lack of access to basic healthcare, but this new research shows the frightening extent of the problem: it’s much worse than we thought. People experiencing homelessness, those with drug addictions, prisoners and those who sell sex are far more likely to develop serious health problems and die early.”

Senior author of the first paper Professor Andrew Hayward from UCL Institute of Epidemiology and Healthcare, said: “It is no surprise that socially excluded groups have poor health outcomes but the extent of the disparities in wealthy countries is an affront to our values. Socially excluded groups are the canaries in the mine – they point to something toxic in our society. Extreme social exclusion affects at least half a million people in England every year, but the true figure is likely to be much higher, as national datasets do not ask about these problems. Exclusion, and its health consequences, often result from many years of multiple problems such as poverty, adverse experiences and psychological trauma during childhood.”

Determining the disease burden in inclusion health populations is an ongoing challenge. Although the feasibility of a coordinated approach to routinely recording membership of inclusion health populations without reinforcing stigma is unclear, the authors of this paper identified the potential for the use of data linkage methods to match data from services that work with inclusion health groups, with vital registration data, electronic health records and existing surveillance systems. At a workshop with people with experience of social exclusion – known as experts by experience – most workshop participants agreed collection of operational data of this kind with ethical and research governance approvals, but without individual level consent, would be acceptable.

The second paper (Luchenski et al) outlines a range of interventions that work to help excluded people including drug treatment, case management, and psychological therapies. Broader work to tackle poverty, unemployment and housing problems can also prevent social exclusion but have been less well studied for their health effects.

Public health fellow and lead author of the second paper Serena Luchenski, from the UCL Institute of Health Informatics, said: “Our research shows how best we can support the most excluded. We urgently need investment and co-ordination between government, health services and social care providers to deliver high-quality comprehensive services in the community, on the streets and in institutional settings such as prisons and hospitals. Supportive values include providing time, building trust, promoting accessibility, fairness and equality. The inequity we have shown is preventable,”

The researchers also highlight previous studies which have shown that “housing first models”, which give people a stable place to live before addressing addiction or mental health problems, can be effective in improving health and social outcomes and reducing crime.

In reviewing inclusion health interventions, the authors of the second paper collaborated with experts by experience. Through a workshop designed to contextualise the review findings, housing was ranked as the most important inclusion health intervention, when participants ranked interventions in order of importance by workshop participants.

Professor Suzanne Fitzpatrick, Director of the Institute for Social Policy, Housing and Equalities Research at Heriot-Watt University and co-author on the second paper, said: “The single most important thing we can do to prevent social exclusion is to tackle poverty, particularly amongst children. This is the key structural driver of homelessness and the other forms of social exclusion considered in these papers. In the UK that means, at a minimum, rolling back the current programme of welfare reform cutbacks that are set to drive child poverty up substantially in the coming years. Social housing plays a vital role in mitigating the worst effects of poverty for many families, but there is a desperate shortfall. Theresa May's recent announcement of 5,000 extra social homes per year in England is welcome but nowhere near enough.”